Doreen Miller

Date of report	26 May 2017
Reference	2017-0169
Deceased	Doreen Miller
Coroner	David Ridley
Coroner area	Wiltshire and Swindon
Category	Hospital Death (Clinical Procedures and medical management) related deaths
Organisation named	Great Western Hospitals NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	none published
The report

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.
DAVID W G. RIDLEY
Senior Coroner for Wiltshire and Swindon

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Ms Nerissa Vaughan

Chief Executive

Great Western Hospitals NHS Foundation Trust
Marlborough Road

Swindon

SN3 6BB

Managing Director

Wiltshire Health & Care
Chippenham Community Hospital
Rowden Hill

Chippenham

Wiltshire

SN15 2AJ

Corporate Director

Adults Social Services (acting)
Wiltshire Council

Bythesea Road

Trowbridge

Wiltshire

BA14 8JN

CORONER

| am DAVID RIDLEY, Senior Coroner for Wiltshire and Swindon

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 19" January 2016 | commenced an investigation into the death of Doreen Helen MILLER and
opened her Inquest on Friday 42" February 2016. Doreen was born on 41" November 1931 in
Winchester, Hampshire and sadly died at The Great Western Hospital in Swindon during the
morning of Wednesday 13"" January 2016. She was 84 years old. | concluded Doreen's Inquest
on Wednesday 24" May 2017 having heard 5 days of evidence and recorded as regards her
cause of death the following:-

1a) Hyperthermia and Bronchopneumonia

2) Left ventricular hypertrophy, hypertension, obesity, type 2 diabetes mellitus, chronic kidney
disease and dementia.

At a Pre-Inquest Review (“PIR”) back in February 2017 | directed that Article 2 of the European
Convention of Human Rights was engaged in relation to the investigation and as such when it
came to recording a conclusion on the Record of Inquest | recorded _a Narrative Conclusion

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

which in addition to recording how when and where Doreen died dealt with the central issues
that | had previously determined back at the February PIR. A copy of the Narrative Conclusion is
attached.

CIRCUMSTANCES OF THE DEATH

Doreen was a vulnerable adult and was in receipt of privately funded care in the community in
that her carers would attend during the morning once a day, Monday to Friday. Doreen was
housebound with no close relatives although there was a neighbour who, it is highly likely also
was a vulnerable adult, would help out with basic shopping from time to time. Doreen was a
head strong individual and her family had described her as being careful with money. From
about 2011 onwards she had become more and more withdrawn and began to lose interest in
relation to her personal hygiene and appearance, which was described by family and others as
becoming unkempt. On 20" December 2015 the alarm was raised and paramedics gained entry
to her property to discover that Doreen had fallen inside the flat and she was found lying on the
floor. She was not confused but she failed a 6CIT Cognitive Test and the paramedic was of the
view that Doreen simply did not understand her needs and that she did not have mental
capacity. There were also concerns as regards the state of the flat and possible self neglect.
There were also concerns that a carer may have stolen money. Doreen herself was admitted to
The Great Western Hospital but in the absence of any physical problems arising from the fall she
was released to an intermediate care facility at Athelston House in Malmesbury run by the
Orders of St John Care Trust. The idea was that they would work with Doreen so as to ensure
that her return to independent living in her own home was safe and supported relative to
Doreen’s needs and of course her wishes. Doreen very soon her arrival at Athelston House
began to exhibit extreme toileting behaviour in form of urinating and defecating straight onto the
floor. She showed no interest in using the toileting facilities and an assessment carried out by a
Senior Nurse at Athelston House on 23 December 2015 revealed that Doreen was presenting
with some degree of confusion and was unsure of her surroundings. Whilst there were
improvements insofar as Doreen’s personal hygiene was concerned at Athelston House | was
satisfied that there was no material improvement insofar as the unusual toileting behaviour was
concerned. The preparation for discharge and the making arrangements for discharge were
therapy led by personnel at that time employed by The Great Western Hospital although |
understand that relevant personnel have subsequently TUPE’d over to Wiltshire Health and Care
at some point during 2016 and after Doreen’s death. It was clear from the evidence that the
Multi Disciplinary Team (“MDT”) had concerns in relation to this unusual toileting behaviour
although | was satisfied that appropriate advice from Senior Staff was not fed back into the MDT
Meeting system and as a consequence the subsequent instruction of a GP to assess Doreen
was too generalised in nature and accordingly the very general assessment undertaken did not
reveal an underlying mental impairment. | also found that in an attempt to gather background
information from family members visiting Athelston House that there was a lack of focus in
relation to the nature of the questions which led to an erroneous conclusion being drawn that
Doreen’s unusual toileting behaviour had been long standing issue and essentially was a lifestyle
choice. | found there was no evidence prior to her arrival to support that conclusion to the
degree of behaviour that she was exhibiting in Athelston House. | found as a fact that the
response from the family member that it was a lifestyle choice and the issue was long standing
related to Doreen’s unkempt appearance as opposed to the extreme toileting behaviour. The
Therapy Led Health Care Team visited Doreen’s home and she refused a number of
recommendations including the increase in the care package. She did not expand on her
reasons and if anything closed down the conversation on the subject. Further advice was sought
from the Mental Health Team direct who again appropriately advised that Doreen’s own GP visit
Doreen at Athelston House. That did not happen and there was never an expectation on the
part of the MDT Therapy led members that that would happen before Doreen’s discharge. The
Therapy led Team concluded that Doreen’s leg ulcers could be managed by District Nurses in
the community, Doreen herself wanted to go home and they felt that they could do no more for
her at Athelston House. Arrangements were made for Doreen’s discharge on Monday aq”
January 2016. The possible vulnerable adult neighbour was notified as regards Doreen’s return
as was Doreen’s elderly sister who lives 1% hours away but having confirmed as highlighted by
the Ambulance Crew that Doreen had no provisions apart from the odd packet of biscuits and
cake (that may have been out of date) in the property | found that there was no express request
made to the family to prepare for Doreen’s return and it was assumed by the health care
professional, Mr Roberts, that they would make arrangements between themselves. This was a
naive assumption to make in my view. Doreen returned to her property early afternoon on

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

Monday 11” January 2016. Shortly before 0600hrs the following the morning she activated her
personal alarm and was subsequently found by paramedics to be sat in a cold, dark flat at a
dining table as described in my Narrative Conclusion. Doreen was severely hypothermic and
although she was taken to The Great Western Hospital again and appropriate treatment given,
she died the following morning on the 13" January 2016.

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.

The MATTERS OF CONCERN are as follows. — My Narrative Conclusion as expanded in my
summing up detailed a number of failings the majority contributing to Doreen’s death. The
outstanding concerns which | would like each of the recipients where designated to consider and
which are listed below in no order of severity or importance are as follows:-

a) (Wiltshire Council) When Doreen was admitted to hospital on 20" December 2015 the
paramedics made a safeguarding referral to Wiltshire Council. Due to the fact that the
admission took place on a Sunday the referral fax was sent to the Emergency Out of
Hours Team. | was satisfied having heard a copy of the recording that South Western
Ambulance Service also followed up that fax with a telephone call to the Emergency
Sevices Team who confirmed that the fax had been received. It appears that in triaging
the referral that it was signed off on the basis that Doreen had been admitted to The
Great Western jee Adult Safeguarding Manager at
Wiltshire Council, who confirmed my suspicion that in
relation to the self-neglect issues that they would ordinarily have been left for the team at
Athelston House to address as that from a common sense point of view would be the
most appropriate way forward. There however remained the issue as regards the
possible financial abuse by a Carer of Doreen. | am concerned here as regards the
procedures in place to ensure that safeguarding referrals are properly investigated and
whilst | was satisfied that what happened here did not contribute to Doreen’s death | am
concerned that a safeguarding issue was not followed up and in fact was signed off in
circumstances when clearly it should not have been. | would like you to look into this
matter with a view to reviewing what went wrong and providing assurances as regards
what measures may be introduced to minimise the risk of this happening again in the
future or if no action is proposed to be taken, why no action is to be taken;

b) (Great Western Hospital) In considering the evidence when Doreen was discharged
from The Great Western Hospital initially on the 21*t December 2015, she was sent with
a discharge letter and a 4 page Medivo Summary summarising the paramedics’
attendance on the 20'" December 2015. Of note that summary did not contain any
information that the paramedic had undertaken a 6CIT Cognitive evaluation of Doreen
and that she had failed that assessment. One can never guarantee that another
document will reflect the information contained in the initial report and therefore a
possible way forward could be to ensure in cases where the turnaround through hospital
is short that as part of the Discharge Package that it includes a copy of the Paramedic
handwritten report that would have been provide to Great Western Hospital when she
was admitted. It is however for you to consider how to resolve the concern here that an
important bit of information was not provided to the team at Athelston House;

c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a
general comment, my view in relation to the quality and substance of case notes was
that they were poor in quality. My investigation was hampered due to the fact that the
Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes
failed in that the notes or at least the scanned images were lost and were not available.
Given that some notes were recorded on the Wiltshire Council Care First System and
the evidence was that the Healthcare records would not have been significantly different
my concerns remain. Crucial and important decisions did not contain any rationale as to
why and the basis upon which that decision was being made. As indicated when |

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

d

e

~~

—

summed up the evidence my view is that recording a rationale can act as a check in
relation to the decision making process itself as it forces the author to consider the
process and information that has led to that decision being made.

| also have concerns in relation to the way MDT’s work and reach decisions. The
decisions very much appear to be a consensual decision amongst relevant members of
the team as opposed to an individual making the decision based on information provided
by relevant team members. There was no leadership. My concern as regards this
consensual approach is that no-one actually takes ownership and responsibility for the
decision itself and a consensual approach as evidenced in Doreen’s case can in my
view lead to a situation whereby there is a false sense of reassurance in believing that
nothing more could be done for Doreen that in this case led to wrong decisions being
taken.

(Wiltshire Health & Care) As part of the evidence | heard that Doreen in the opinion of
an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment
more likely with underlying dementia) but also more importantly that in relation to a
serious and complex decision to return home she was of the view, in respect of which |
accepted, that more likely than not Doreen could not understand her needs and was
unable to recognise the risk of refusing the safeguarding recommendations and that in
relation to her decision to return home and those associated decisions that she did not
have mental capacity. | indicated in my summing up that this was a difficult case but |
feel that the training given especially to the Therapy led members of the team did not
sufficiently prepare them to deal with very complicated cases such as Doreen’s although
that having been said if the advice that had been given had been followed the outcome
possibly would have been different. | was however satisfied that had the advice been
followed and a capacity test undertaken that Doreen would not have returned home
when she did and therefore would not have died when she did. It was_also readily
apparent to me that members of the Therapy Led Team and particularly was
unaware that the safeguarding measures, part of the Mental Capacity Act and in
particular the ability to secure either and urgent or standard authorisation for the
deprivation of somebody's liberty was not available where the individual concerned lives
in the community and where their care is paid for privately. As one witness said those
cases can be extremely challenging and essentially those trying to do their best for the
individual essentially have to wait for the next crisis to occur before they may be given
an opportunity to introduce safeguarding measures. Had the mental impairment been
recognised and the mental capacity assessment been carried out revealing that she did
not have mental capacity in relation to the serious and complex decision to return home
and associated decisions concerning additional safeguarding measures and if Doreen
still wished to return home then it may have been in her best interests to have
considered Deprivation of Liberty Safeguarding Order. | would hope that this particular
case in particular could be used as a specific training case by all organisations involved
but | have concerns that there were material gaps in individuals’ knowledge bases.

(Wiltshire Health & Care) Having commenced a Coronial Investigation | tasked
Coroners Officers to make a number of enquiries on my behalf and that included
securing statements. As part of documentation that was disclosed by Wiltshire Health
and Care was an email from Intermediate Care Lead Carol Langley-Johnson, her email
sent to Acting Coroner’s Officer Zon 4" July 2016 contained a final
paragraph that said “/ have no concern about the standards of care provided by my
team, | have read their statements and feel that this is a fair representation of rehab she
received’. As will have been abundantly clear from reading this report and my Narrative
Conclusion | did not share the same view as Ms Langley-Johnson and | am concerned
and surprised that prior to the Inquest Final Hearing that no attempt was undertaken to
carry out any form of Serious Case Review by Wiltshire Health and Care, formerly Great
Western Hospital. | am concerned as regards the system in place that will pick up
serious incidents for review and the mechanism in place to undertake investigations with
a view to learning points being highlighted, the consideration of procedural changes and
the implementation of any changes including additional training needs where required. |
am concerned that there may be other incidences where there are learning points where

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

there has not been a review and whilst those incidents may not have resulted in the
death of an individual that the learning points have not been recognised and therefore
there is the potential out there for repetition and in extreme circumstances repetition of
dangerous practices that may lead to death and the involvement of me and my office.

| would ask respectfully that those recipients of this letter where indicated in brackets consider
the concerns | raised and deal with them

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by
21 July 2017. |, 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.

COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons

Locality Team Manager, Adult Social Care, Wiltshire Council,
Monkton Park, Chippenham, Wiltshire SN15 1ER

Manager, Athelston House, Priory Way, Burton Hill, Malmesbury, Wiltshire SN16 OFB and

HE he Great Western Hospital, Marlborough Road , Swindon SN3 6BB

rincipal Solicitor/Manager, Transcare Law, 1 Admiral Way, Doxford
International Business Park, Sunderland SR3 3XP

New Court Surgery, Borough Fields, Royal Wootton Bassett,
Wiltshire SN4 7AX

Malmesbury Primary Care Centre, Priory Way, Malmesbury, Wiltshire SN16 OFB
and Medical.London@Medicalprotection.org — ref:LH983999

| have also sent it to Care Quality Commission - CQCinquestsandCoroners1 @cqc.org.uk
and

Chair, NHS Wiltshire Clinical Commissioning Group, Southgate House, Pans
Lane, Devizes, Wiltshire, SN10 5EQ who may find it useful or of interest.

lam 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.

Dated 26 May 2017

Signature SS ~ s.

Senior Coroner for Wiltshire and Swindon

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Satisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
The report

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