Dementia Sufferer Died Under Care Of High-Risk Trust Because Hospital Staff Failed To Follow Guidelines

Trust Admits Failures As CQC Announces Radical Changes To Hospital Inspections


By Helen MacGregor

The heartbroken family of a dementia sufferer who died after hospital staff over-sedated him causing him to fall and suffer a serious head injury have spoken of their relief that the hospital trust responsible has given reassurances that lessons have been learnt.

Peter Ryley, died in January 2011 after nursing staff at the Queen’s Medical Centre in Nottingham gave him multiple doses of a sedative to ‘keep him quiet’ due to his dementia and staff failed to implement a falls risk assessment which would have meant he could not fall and seriously injure himself.

His wife, Patricia Ryley and son Andrew from Long Eaton, Nottinghamshire, instructed medical law experts at Irwin Mitchell to investigate whether more could have been done to prevent the 76-year-old’s death.

Nottingham University Hospitals NHS Trust recently admitted full responsibility for Peter’s death and agreed to act on a number of failings identified in an internal investigation launched by the Trust. Recommendations that will be acted on include:
• The Trust should urgently implement a sedation guideline for patients with agitation
• The trust should consider how to improve compliance with the Trust Falls Management policy
• Expert dementia support should be made readily available to all wards without delay

Andrew is speaking out as the Care Quality Commission (CQC) announced Nottingham University Hospitals NHS Trust as one of six trusts marked as being high risk for patient care and one of the first to undergo a new inspection regime unveiled by the CQC today (18 July).

It was announced that the CQC’s new Chief Inspector of Hospitals, Professor Sir Mike Richards will introduce radical changes to the way hospitals in England are inspected to try and turn around the high risk hospitals. Following on from the review carried out by Bruce Keogh, the changes – including larger inspection teams and both planned and unannounced visits - will be introduced by the end of next month.

Andrew, a postman aged 44, said: “Dad was admitted to QMC after suffering bowel problems for some time but it soon became clear that staff were so overstretched they didn’t have the necessary resources to care for him.

“I was regularly by his side in the three weeks he was in hospital to help and make sure he had everything he needed but obviously I couldn’t be there 24/7. Dad’s dementia meant he did need a lot of care but rather than reassuring him and trying to keep him occupied it came to light at the inquest that the medical staff just kept increasing his sedation levels.

“In the end he was practically delirious from all the drugs he had been given but no steps were taken by the nurses to prevent him from being a danger to himself.”

He added: “We have been left devastated by the way Dad was treated. He should have been shown some dignity and respect in his final days but sadly the main goal of the nurses and doctors was to keep him quiet. The admission and reassurance will never bring him back and we will always hold them responsible, but does give us some justice and peace of mind that lessons have been learnt. Although i must admit that i am very disappointed that after all of the reassurances that we were given by the trust that they are one of the six mentioned by the CQC.

“I am pleased that the CQC is taking action to try and improve patient care, particularly at the trusts marked high risk, and hope this will help to prevent anyone else going through the same ordeal as my father.”

Peter was readmitted to QMC on 3 January 2011 after being discharged just two days earlier because he was suffering from prolonged constipation. He was given a sedative soon after arrival which then continued multiple times throughout each day despite a doctor expressing concerns that he should be given nothing further.

On 14 January a falls risk assessment identified Peter as being high risk and a care plan was created recommending additional night staff to help care for him, a nurse to be visible at all times and to consider lowering his bed. 

On 17 January Peter fell again, and he was found unconscious and bleeding. The care plan that was created for Peter was never implemented.

X-rays showed he had suffered a severe brain haemorrhage and he died five days later. An inquest in September 2012 recorded a narrative verdict and the Coroner noted an ongoing oversight in complying with the Queens Medical Centre’s Fall Prevention Policies and a continuing and escalating use of sedation.

Anna Manning, a medical law expert at Irwin Mitchell representing the family, said: “Peter was referred to hospital where it was hoped he would receive treatment to help his constipation. 

“Sadly, it seems his condition rapidly deteriorated rather than improving and hospital staff appeared to have been plying him with different sedatives rather than engaging with him to keep him calm.

“On top of this, the care plan which had been produced after Peter was identified as being at high risk from a fall was never implemented. If this had been done then Peter would not have suffered the serious head injuries from the fall, which sadly led to his death.

“We welcome the news that the CQC is to introduce radical changes to inspect hospitals and improve standards of care and patient safety. We see firsthand how distraught some families, such as Peter’s, are at losing loved ones when care standards have been poor. We hope it is the first step in a long path of restoring the public’s faith in the NHS and improving patient safety.”

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