Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0168, written 29 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2016 |
|---|---|
| Reference | 2016-0168 |
| Deceased | Jack Molyneux |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner THE CORONER’S OFFICE WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Assistant Coroners BS eA, ge Telephone: Brighton CATHARINE PALMER LL.B (HONS) SELL EL RERION Dl? Fax: Brighton] KAREN HENDERSON, BSC,BM,MRCPI,FRC. - GILVA D.J.TISSHAW, BA(LA W)HONS CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Dr Gillian Fairfield, Chief Executive, Brighton Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 2 CORONER’S LEGAL POWERS © : | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 5" February 2016 | commenced an investigation into the death of Jack MOLYNEUX. The investigation concluded at the end of the inquest on 22%? April 2016. The conclusion of the inquest was a NARRATIVE CONCLUSION ~ Please see attached sheet. 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPLFRC. - GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 The MATTERS OF CONCERN are as follows. — Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer's and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above. Mobility He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his outdoor clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month. His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth. His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it. With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: oviohor CATHARINE PALMER LL.B (HONS) Fax: Brightor KAREN HENDERSON, BSC,BM,MRCPI,FRC.- GILVA D.J.TISSHAW, BA(LA W)HONS At the Inquest | found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing to his death. | believe this to be one of the most disturbing cases of sub optimal care that | have come across recently and | am not at all satisfied that this Inquest will result in any effective action being taken which is why | am concerned to follow up this matter and to ensure that all those who should know about this situation are informed. Certainly | found that the above omissions and failings contributed to Mr Molyneux’s death. When he arrived at the nursing home he came on the evening of the 25" January and on the 26" the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26" or 27". His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content. Finally, it is of note that an urgent DOLS was put in place on the morning of the 27" January 2016. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22" July 2016. |, the coroner may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners (A e Fe ASN Telephone: Brighton CATHARINE PALMER LL.B (HONS) ea ELAS a Fax: Brighton KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LAW)HONS 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Secretary of State for Health, Department of Health Simon Stevens — Chief Executive NHS England National Patient Safety Agency Clinical Commissioning Group - Director of Public Health , ¥£ Chair of BSUH NHS Trust ~ Director for Clinical Quality and Primary Care 2 TFT Care Quality Commission . | Medico-Legal Services | have also sent it to:- OHNOARONS 1. 2. 3. Who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Date: 29" April 2016 jy whan SIGNE pe vole Senior Coroner Brighton andHove
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