Inquest Identifies Care Issues At Endeavour Court Mental Health Ward

The devastated family of a Wolverhampton man who died as a result of choking on his vomit are calling for lessons to be learned after an inquest identified a number of issues in his care.

Daniel Turner, 34, had a long history of mental health issues, including a diagnosis of paranoid schizophrenia.  In September 2020, he was detained under Section 3 of the Mental Health Act at Endeavour Court in Erdington, Birmingham, a locked high dependency mental health ward.

He was under 15-minute observations.  During the early hours of 29 November, Daniel was found by staff having difficulty breathing and making gurgling sounds.  He didn’t respond to his name being called and staff activated the alarm before commencing CPR, the inquest heard.

An ambulance was called by staff on Endeavour Court approximately 10 minutes after Daniel was first found in distress, despite Trust policy and resuscitation training and guidelines stating that an ambulance should be called immediately in circumstances such as this.  Paramedics took over and continued CPR.  Daniel, however, remained unresponsive.  He was sadly pronounced dead shortly afterwards.

Following his death, Daniel’s family, including his mum Dawn Williams, instructed expert lawyers at Irwin Mitchell to investigate his care under the Birmingham and Solihull Mental Health NHS Trust which runs the Endeavour Court, and support them through the inquest process.

Together with their legal team at Irwin Mitchell, the family is now calling for lessons to be learned to help prevent future tragic deaths.

The inquest heard about a number of failings in Daniel’s care by staff in Endeavour Court.

These included:

• Evidence of poor communication and exchange of clinical information about a previous serious choking incident that Daniel had suffered in August 2020 on another ward. Whilst this was mentioned in the inpatient notes, this wasn’t included in the risk assessment summary for Endeavour Court and hadn’t been discussed with the nursing team at Endeavour Court. There had been no Multi-Disciplinary Team (“MDT”) discussion about the incident and evidence was heard that if there had been then a re-referral would have been made to Speech and Language Therapy to consider ongoing risk to Daniel.
• The Speech and Language Therapy plan for Daniel, which included details of the choking incident and recommendations, was closed by Daniel’s named nurse on 2 October. This meant that the choking incident was not immediately evident to staff when looking at the care plan for Daniel. Daniel’s named nurse said in evidence that in hindsight she should not have closed the plan without discussing the choking incident with the MDT and referring Daniel back to Speech and Language Therapy.
• Nursing staff had not read Daniel’s clinical records and only became aware of the previous choking incident following Daniel’s death.
• There was only one member of immediate life support (ILS) trained staff on the ward as the nurse in charge had failed her ILS training.
• Two staff members were on break at the same time, reducing the number of staff on duty at the time of Daniel’s death.
• An ambulance was not called immediately by the nurse in charge who found Daniel unresponsive despite this being Trust protocol and in line with national resuscitation guidelines and training. There was a subsequent delay in the paramedics attending.
• A delay in staff accessing the office to call an ambulance as they were unable to identify the correct key due to a number of keys that “looked the same”.
• An immediate life support (ILS) response wasn’t immediately available as Daniel’s named nurse who was also the nurse in charge had failed the ILS training but this hadn’t been communicated to their manager, despite their professional obligation to do so, and no contingency plans were put in place.
• If the ward manager or Matron had been aware of this the nurse in charge would not have been on the night shift with Daniel when he died and alternative arrangements would have been made for someone who was ILS trained to cover that shift.
• The ward did not have a cordless phone and when calling the ambulance staff were unable to take the phone to Daniel and receive instructions from the 999 operator as to how to proceed.
• A delay in paramedics arriving at the ward due to confusion as to the location of the ward.
• Staff did not follow the Trust’s resuscitation policy and protocol on the day of Daniel’s death.

Following the Trust’s internal investigation into Daniel’s death, the Trust made a number of recommendations.  These included reducing the number of keys held by staff and considering the installation of swipe locks, as well as improved planning of breaks and safer staffing.

It was also recommended that a robust review of assessment documents is undertaken for all new admissions and transfers to Endeavour Court to enable discussions around care planning and risks assessment to take place.  It was also recommended to change the ward name to avoid confusion in future.

An inquest jury concluded that Daniel died as a result of aspiration of gastric contents and that his position and reflux contributed to his death. Following the jury’s conclusion the Coroner considered whether she needed to write a report to the Trust regarding a continuing risk to life that requires action. The Coroner concluded that she was reassured that the Trust had confirmed the action it had taken and the plan it has to remedy the failings in Daniel’s case. The Coroner went on to say that she and other Coroners will be monitoring that these matters do not arise again in any future dealings with the Trust.

Expert Opinion

“Understandably Dawn and her family have been left devastated by Daniel’s tragic death.

For almost a year now, they have had concerns over Daniel’s care and it’s been incredibly difficult for them reliving everything that happened that day. Sadly, the inquest and the Trust’s own report has identified a number of issues and concerns in Daniel’s care.

While nothing can make up for what Daniel’s loved ones have lost, we’re pleased to have at least helped get them the answers they deserve.

We now call on the Trust to learn lessons and ensure recommendations for improving care are implemented to prevent similar future tragic deaths.”
Sophie Farrah - Associate Solicitor

Nancy Kelehar, the INQUEST Caseworker who supported the family, said: "As an organisation, we are concerned about the communication issues regarding Daniel's clinical history and the impact that this had on his care and treatment. NHS Trusts across the board must work to ensure that key information about those to whom they owe a duty of care does not fall through the gaps in order to prevent further unnecessary and tragic deaths."

Dawn is also mum to Daniel’s brothers Kyle Wright, Callum Wright and Finn Graham.

Following the inquest, she said: “It’s been almost a year since we lost Daniel but I still struggle every day to come to terms with him no longer being here.

“He suffered with his mental health for a long time but we believed he was in the right place to get the help and support he needed.  It was heart breaking when we were told he had died.  It’s been particularly difficult for me to face losing my first born son as a parent should never have to bury their child.

“The inquest has been really tough on us all, having to relive what Daniel went through, but we are grateful to finally have some answers.

“We are very grateful to the Coroner for her thorough and meticulous inquiry into the circumstances of Daniel’s death. She instilled confidence in us throughout the process and we feel that our voices were heard.

“I know there’s nothing we can do to change what happened, but all we hope for now is that something is learned from our loss to stop others from going through the pain and suffering we have.”

Find out more about Irwin Mitchell's expertise in handling public law and human rights cases