Hospice Patient Was Left Unchecked For Two-And-A-Half Hours Prior To Death

The devastated widow of a Hampshire man found dead beside a car park while in respite care has spoken out on her loss.

Michael Curtis, 76, from Andover, had a number of medical conditions and was suffering from blood cancer.  Around March last year, his condition began to deteriorate, with him showing signs of confusion and unsteadiness linked to a pre-existing heart condition.  He was admitted to the Countess of Brecknock Hospice in the grounds of Andover Hospital for respite care.

Four days later, Michael woke frequently in the night and was found out of bed on more than one occasion.  He remained unsettled and staff were told to ‘keep an eye on him.’

The following morning, a passer-by found Michael dead outside near to the hospital car park.

Following his death, Michael’s wife Penny, 75, instructed medical experts at Irwin Mitchell to investigate her husband’s care under the Hampshire Hospitals NHS Foundation Trust.

An investigation report published by the NHS found Michael was left unchecked between 4.30am and 7am, with one member of staff on a break from 4.20am to 6.20am which was double the allowed one hour and “would have increased the pressure/workload for the whole team.”

Michael was found around 170 metres from his exit route from the hospice. He had left the first floor, moved down two flights of stairs and into a section of the hospice that was still under construction. Michael then walked through the exit door and into the builder’s compound.

CCTV footage recorded Michael’s entire journey and showed him moving from the builder’s compound through the unlocked gate and along the perimeter fencing. Michael then continued to walk up the road and into the car park. He finally made a turn that would lead him back to the hospice where he collapsed and was found by a passer-by.

Further to this, it was found that Michael’s medication had not been administered at 6am as it should have been.  The report states “had the nursing staff attempted to give this, they would have noticed the patient was missing earlier and looked for him at this time.”  Furthermore, the next ward round “was due at 6.30am and not completed.”

In addition, it was reported that the fire door and stair gate that Michael left from was merely on a latch with no alarm system in place. Once Michael had unlatched the door, it locked behind him and he had no way of re-entering the building.

The Trust’s report advised that the door should have been alarmed which would have alerted staff to Michael and allowed them to return him to the safety of his room.

Recommendations made in the report included the introduction of hourly rounding alongside a process to ensure its completion, as well as a formal risk assessment as to whether the fire door should be fitted with an alarm and an investigation into the conduct of staff on shift overnight.

The Trust has now admitted a breach of duty and accepts a failure to ensure Michael was “appropriately monitored and kept safe during his time at the hospice.”

Joe Haley, the medical negligence specialist at Irwin Mitchell representing Michael’s loved ones including Penny, said: “The past year has been incredibly difficult for Michael’s family, particularly Penny who is still struggling with coming to terms with losing her husband so tragically.

“Through our work we sadly come across many people left devastated following the death of a loved one.  While nothing will ever make up for what’s happened or bring Michael back, we’re determined to support Penny and her family by providing them with the answers they deserve.

“Meanwhile, the NHS report has identified some worrying issues and omissions in Michael’s care and we now urge that any recommendations are implemented as soon as possible to improve on patient safety.”

Michael had a number of medical conditions that concerned his family.  As his condition deteriorated, Penny said night times became difficult as Michael was confused and at risk of falling down the stairs.

On the advice of his palliative care team, Michael was admitted to a hospice temporarily on 12 March, 2020, with the potential of being place in a residential nursing home in the future.

A 72-hour monitoring chart commenced and a bed rails assessment was completed on 14 March, with bed rails not recommended.

On 16 March, Michael woke several times in the night and, at one point, was found asleep in his chair.  Later that day, he was visited by his family and was reported to have asked Penny where her car was parked.

During the nurse’s handover that evening, it was decided not to give Michael a falls mat and that staff would check on him to ensure his safety.

Michael remained unsettled throughout the night and was found sitting on the edge of his bed.

At around 3am on 17 March, he was assisted back to bed, and at 4.30am he was noted to be awake and sitting on his bed.

Michael wasn’t checked on again and was found dead at around 7am.

Penny, who was married to Michael for 56 years, said: “I think about him every single day. When he was diagnosed with cancer a number of years ago we were absolutely devastated but it was being monitored and managed well. We were in no way prepared to lose him in the way we did. Michael had suffered from a complex medical history that included more than just his cancer.

“Michael went into the hospice for some respite care; I didn’t think for one minute he wouldn’t be coming out.  He was a real fighter. We were looking forward to becoming husband and wife again, rather than just patient and carer. We never got that chance.

“His feet were swaddled at the time, which made mobility very difficult, and when he was found, he had covered a fair distance with no walking aid which must have been very tough on him.  It was also frosty outside and he was in his pyjamas.

“I would give anything to turn back the clock and see Michael one last time, but I know that’s not possible.  All I can hope for now is that by sharing our story, I can make others aware of how confusion can potentially affect someone.  I wouldn’t want anyone else going through what I have.”

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