NHS Trust Admits Liability After Widower Instructs Medical Negligence Experts At Irwin Mitchell Solicitors

The family of a Lowestoft mum who died from a blood clot after becoming dehydrated while a patient at a mental health unit has received an official apology from Norfolk and Suffolk NHS Trust’s Chief Executive, more than four years after her death.

Denise Davies, who had a history of anxiety, but was otherwise well, died aged 45 after suffering a deep vein thrombosis shortly after she was transferred from the care of Norfolk and Suffolk NHS Mental Health Trust to the James Paget Hospital with fears over her deteriorating physical health.

Following her death, the mum-of-two’s family instructed specialist medical negligence lawyer, Thomas Riis-Bristow at Irwin Mitchell who commenced an investigation into the standard of care Denise received before her death.

After a lengthy legal battle, Norfolk and Suffolk NHS Trust, has now officially apologised to Denise’s husband Mark, 55, and their children Rachel, 26, and Ashley, 22. It comes after the NHS Trust admitted failures in Denise’s care whilst she was at Carlton Court Mental Health Unit and failures during her transfer to the James Paget Hospital.

Denise, a former NHS healthcare support worker, was the sole carer for Mark who was forced to retire from his job as a prison officer because of a degenerative spinal cord condition, which has left him paralysed. They had been married for 24 years. Thomas Riis-Bristow from Irwin Mitchell Solicitors has secured the family an out-of-court settlement to help provide the care for Mark that Denise would have provided had she survived.

Julie Cave, Chief Executive of Norfolk and Suffolk NHS Trust has written to Mark offering ‘personal apologies’ for Denise’s care and ‘sincere condolences’ for her death.

She added: “I am aware that the standard of care provided to Denise fell below that which she was entitled to expect and which this Trust strives to offer, I am sorry that the care provided to Denise did not meet the expected standards and I am very sorry to hear of the tragic loss of your wife, Denise, subsequently.”

Ms Cave said that the Trust “continues to works very hard to ensure that the quality of its healthcare services improves.”

Expert Opinion

Denise’s family has suffered unimaginable loss and a great deal of stress and anger for more than four years as they sought answers from Norfolk and Suffolk NHS Trust regarding her death.

“Denise was tragically let down by the Trust when she was at her most vulnerable, with devastating consequences. Sadly, her family now has to go on without Denise and the only positive they take from the conclusion of the legal case is that they have pursued the matter to the full extent that the law will allow.”

“The Trust was the first ever Mental Health Trust placed into special measures by the Care Quality Commission in October 2014 as it was deemed to be providing an ‘Inadequate’ standard of care. Despite this request to improve, the Davies family were stunned to learn that the Trust was placed into special measures for a second time in October 2017.

“While nothing can make up for Denise’s death, the Trust’s admission and apology fully vindicates the family’s four year quest for answers. The family feels they have honoured Denise’s memory in legally establishing the Trust failed her when she needed it most”.

“However, they are shocked that, despite the Trust saying it has learned lessons from her death, the number of unexpected deaths at the Trust has continued to rise. It is vital that this failing Trust urgently improves and puts measures in place to ensure other families have to suffer the heartache that Mark and his family have.” Tom Riis-Bristow - Senior Associate Solicitor

Mark said: “Our family has been ripped apart by Denise’s death. I lost my best friend and Rachel and Ashley have lost their caring and loving mum.

“As if that was not hard enough to come to terms with, we had more than four years of fighting Norfolk and Suffolk NHS Trust until it finally admitted failings in the care it provided to Denise.

“We were told that changes had been made following her death. Changes may have been made but I’m sceptical as to whether enough is being done. The number of unexpected deaths continues to rise significantly and the Trust has been put in special measures for a second time. I feel that something needs to be done to stop the numbers of unexpected deaths increasing at the Trust year on year.

“Mental illness can affect anyone at any time and from any walk of life.  I am speaking out to shine a light on what happened to Denise and I am calling on the government to ensure that significant investment is made into improving mental health services in the UK.

“This issue is not going to go away and can’t just be brushed under the carpet. People need to be more open about how they feel and help ensure there is awareness about depression and mental illness. Hopefully by speaking out about my case, there will be more exposure to this issue and that this will make the authorities realise how important it is to improve NHS mental health services.”

Background

Denise was admitted as an inpatient to the Northgate Unit of the Trust on 2 June 2013, following a deterioration in her mental health and concerns she was not eating or drinking. She was transferred to the care of Carlton Court Mental Health Unit on 3 June, 2013. A medical assessment requested close monitoring of her fluid and nutritional intake. Sadly, her physical condition continued to deteriorate and she required transfer to James Paget Hospital in Great Yarmouth four days later for intravenous rehydration and required anti-clotting medication.

However, the doctor who transferred her from Carlton Court sent her with a handwritten note on a scrap of paper in a taxi with a mental health nurse to accompany Denise. The doctor was in breach of the Trust’s appropriate safe transfer protocols.

Following her transfer, on 9 June 2013, Denise was found collapsed having suffered a cardiac arrest. Despite attempts to resuscitate her she died shortly afterwards.

The family’s legal team argued that that Norfolk and Suffolk NHS Trust had failed to carry out and repeat daily appropriate risk assessments to avoid the risk of deep vein thrombosis and malnutrition occurring whilst Denise was a patient at Carlton Court Mental Health Unit.

It was accepted by the Trust that Denise should have been transferred to the James Paget Hospital for urgent intervention on either the 4 or 5 of June 2013. Denise did not receive this treatment until early evening on the 8 June 2013.  As a result of Denise’s death, both Trusts have since collaborated and have prepared a tailored transfer form, which must be completed in circumstances where patients with mental health issues are transferred between the Trusts.

Norfolk and Suffolk NHS Trust’s annually reported number of unexpected death rate was 53 in 2012/13 and this rose to 105 in 2013/14 and rose again to 139 in 2014/15 and yet again to 158 in 2015/2016. According to the Trust’s latest 2016/17 annual report, this number has further increased to 184 unexpected deaths as at the end of March 2017. This is a 247% increase in unexpected deaths since 2012.

A two-day inquest in March 2015 heard that Denise died as a result of a pulmonary embolism - a blood clot restricting blood flow to her lungs - which developed due to a combination of factors prior to her death, including; dehydration, immobility, repeated failures to ensure risk factors for developing a blood clot were managed and an avoidable delay in transferring Denise to hospital for appropriate treatment.

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