Norfolk & Suffolk NHS Foundation Trust Placed Into Special Measures

A mother-of-two died after medical staff made a ‘catalogue of errors’ including a 26 HOUR delay in giving her life-saving treatment after she was admitted to hospital with concerns that she was ‘profoundly dehydrated’.

Denise Davies, from Lowestoft in Suffolk, died following a short admission to Carlton Court, a Suffolk Mental Health Unit (part of the Norfolk and Suffolk NHS Trust recently been put into special measures by the Care Quality Commission (CQC).

A two-day inquest into her death concluded on 20th March 2015 at Norwich Coroner’s Court. The Coroner’s conclusion was handed down today (24th March) and HM Coroner for Norfolk and Suffolk, Ms Jacqueline Lake recorded a verdict of natural causes against a background of dehydration and said: “This case has found many concerns, lack of information and communication, of the view that it is important that there are clear lines between both hospitals, the standard of record keeping has been very poor. Record keeping should be fully and properly completed particularly when transfers taking place.

“Delays in treatment, can explain some but other delays remain unexplained and this wasn’t satisfactory – I do remain concerned no plans were in place. Heard from both trusts that the action taken following her death and I am satisfied with the steps that have been put in place by both hospitals.”

Denise’s husband, Mark Davies, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate her treatment whilst under the care of the Carlton Court Mental Health Unit and the James Paget Hospital as he was concerned that more could have been done to prevent her death by the staff responsible for caring for her.

During the two day inquest, the Coroner heard that Denise died as a result of a pulmonary embolism (a blood clot restricting blood flow to her lungs).  The Court heard that in the days before her death whilst at Carlton Court it took 22 HOURS for a senior doctor to review her care and there was a failure to give required medication and there was a 1 – 2 day delay in transferring her to a suitable hospital.

Denise was admitted as an inpatient to Carlton Court on 3rd June 2013 following deterioration in her mental health. She had not been eating and drinking well at home and so when she arrived, it was recorded that Denise was at risk of becoming physically unwell as she was not eating or drinking.  She required regular medical and physical observations to maintain both her physical as well as mental wellbeing.  However, this did not happen and her husband repeatedly raised concerns with the unit.

The Trust’s own investigation found a number of failings including a failure to monitor Denise’s temperature, pulse, breathing and blood pressure from the morning of 4 June 2013 (which were abnormal at this time), despite a decision at admission that she required regular medical reviews.  They also failed to monitor fluid input and output despite concerns of dehydration.

The inquest heard that Denise received NO MEDICAL REVIEW or physical observations between the 4 and 7 June 2013 until she was finally reviewed and transferred to James Paget Hospital in the early evening of 7 June 2013 when she was found to be ‘profoundly dehydrated’.

Dr Kharbteng, a Consultant Psychiatrist at the Mental Health Unit, gave evidence during the inquest and advised the Coroner that Denise should have been referred to hospital between 1-2 days earlier than she was. He advised the Coroner that, had Denise’s physical health been appropriately monitored, they would have noticed deterioration in her condition sooner and she would have been transferred to hospital earlier. hen asked why an on-going medical review did not take place he said that resource issues contributed to this delay.

On admission to James Paget Hospital early evening on 7 June 2013, Denise required urgent medical treatment as she had not been eating or drinking properly for a number of days.  However, she was not given an IV drip to hydrate her until 20:00 hours the next day, a delay of 26 HOURS, and they failed to give anti-clotting medication. The inquest heard that there was whole scale confusion over how their duties in treating a patient without mental capacity leading to critical delays in her treatment.

Denise continued to deteriorate which was not noticed and on the morning of, 9 June 2013 Denise was found collapsed having suffered a cardiac arrest. Despite attempts to resuscitate her she died shortly afterwards.

Expert Opinion

This is a truly tragic case – Denise was the sole carer for her husband who is wheelchair dependent. Although Denise had a history of depression, this was previously well managed. When her condition deteriorated suddenly, her family reached out to her GP to try and get Denise the help and support she needed as she was unable to care for herself and becoming physically unwell. When she was admitted to the Mental Health Unit in Suffolk, they felt reassured and trusted that she was in the best possible hands.

“Unfortunately, the stark reality is that her death may have been avoided had the clinical staff responsible for her care taken appropriate measures to ensure both her physical and mental wellbeing were maintained.

“Denise’s family are very concerned having learned that Norfolk and Suffolk NHS Foundation Trust, the Trust responsible for Carlton Court, has recently been put into special measures by the Care Quality Commission (CQC) due to reports of inadequate and poor care throughout its mental health units. This is the first time a Mental Health Trust in England to be placed into special measures.

“The key priority at this stage must be to ensure that services and standards at the Trust are improved quickly, with a view to ensuring patients are able to access the safe and high-quality care that they deserve.”
Tom Riis-Bristow - Senior Associate Solicitor

Commenting after the inquest, Mark said: “Losing Denise so suddenly has been absolutely heartbreaking for our family. We put our faith in the hands of the staff caring for her and we trusted that they would provide the very best care she desperately needed. We feel that they have completely let her and us down.

“I would like to thank the Coroner for carrying out a full and thorough investigation into the events surrounding Denise’s death. We hope that some good can come out of all of this to help ensure that lessons are learnt and similar deaths are avoided in the future as we would not wish for another family to go through what we have suffered.”

The facility run by the Norfolk and Suffolk NHS Foundation Trust has become the first mental health trust in England to be placed in special measures, after it was given an overall rating of inadequate by the CQC earlier this month.

Both of the NHS Trusts responsible for Denise’s care confirmed that key changes have been implemented following Denise’s death, which are:

Norfolk and Suffolk NHS Foundation Trust

• They have are updated their pulmonary embolism assessment and treatment policy and further training is being provided to clinical staff;
• That training has been implemented for all staff to make sure they are competent to assess and understand the importance of physical wellbeing and to identify deterioration in physical wellbeing before it is too late;
• There is better access to and training conducted by physical health nurses;
• There is now improved communication channels between both Trusts;
• A new standard transfer form has been produced in cooperation with the James Paget Hospital to ensure adequate information is provided when transferring a mentally ill patient to hospital for medical treatment.

James Paget University Hospitals NHS Foundation Trust

• There is now improved communication streams between both Trusts with regard to transfer of mentally ill patients to JPUH;
• There is a new transfer form, which must be completed by the Mental Health Unit transferring a patient to the hospital to help ensure seamless transfer of patients;
• A new training programme has been implemented to train clinical staff to understand Mental Capacity and the appropriate steps to take in such clinical scenarios;
• That new guidance documentation has been produced for clinicians, including a mental health assessment tool which has been communicated to staff within the Trust to assist clinicians when assessing a patient’s mental capacity;
• There is a new appointment of a lead clinician at the Trust who is now responsible for all enquiries in relation to treating mentally unwell patients admitted to the hospital.

Expert Opinion

The evidence given during the inquest and the details of both NHS Trust’s investigations show there were multiple failures in Denise’s care. The significant number of changes made by both Trusts demonstrates that appropriate safety netting was simply not in place at the time of her death.

“Whilst changes have been made following Denise’s death, for her family it is now too little too late. They only hope that by speaking out about their experiences that lessons are learnt and improvements are made to the way in which mentally ill patients are treated. They are calling for a review of the way in which mental health care is delivered across the NHS as a whole.” Tom Riis-Bristow - Senior Associate Solicitor