Jury Records a Narrative Conclusion Highlighting Failings in Care Which Led to His Death

The family of a Sheffield man who died after he was found hanging at a mental health unit has urged that lessons are learned following an inquest into his death.

Keith Dransfield was detained under the Mental Health Act after a rapid deterioration in his mental health, having expressed suicidal intent. He was detained and admitted into the protective custody of Sheffield Health and Social Care NHS Foundation Trust on 26 September 2017.

Keith was found in the en-suite bathroom in his bedroom at The Longley Centre in Sheffield during a routine observation by staff three days after he was detained.

Staff resuscitated the 70-year-old and he was transferred to the Northern General Hospital having suffered catastrophic brain injuries and was placed on life support. However, he sadly died the following afternoon with his family by his side.

Following his death, Keith’s family instructed specialist medical negligence experts at Irwin Mitchell to investigate his care under Sheffield Health and Social Care NHS Foundation Trust, which runs The Longley Centre.

His wife Gillian has now instructed Irwin Mitchell, calling for lessons to be learned.

It comes after an internal investigation carried out by the Trust found the ‘root cause’ of Keith’s death was a result of staff underestimating the risk he posed to himself, and because of a ‘lack of robust assessment.’

The jury answered 10 questions which formed the narrative conclusion. As a majority of seven to one it found there was no written justification for reducing Keith’s observations from 10 minute intervals to routine observations. In all of the circumstances the jury found that the reduction in his observations was not justified.

It also concluded that the staff on the ward did not consistently consult the written records of the patients allocated to them, nor were they properly trained. Keith was also not subject to an appropriate risk assessment regarding his mental health. The jury found that a member of staff should have increased his level of observations to 10 minutes.

Had Keith been on 10 minute observations, the jury as a majority found that it was more likely that he would have survived. Overall, the jury found that the level of care Keith received fell short of an appropriate standard.

The Chief Executive and the Deputy Chief Executive of Sheffield Health and Social Care NHS Foundation Trust issued an apology at the inquest, and offered their deepest condolences and sincere apologies to Keith’s family.

The Coroner, Mr Urpeth has also issued a Preventing Future Deaths Report in light of the jury’s findings.

Expert Opinion

This is a truly devastating case and the inquest has understandably been a very difficult time for Keith’s loved ones, who are still struggling to come to terms with his sudden and untimely death.

“Both the NHS Trust report, and now the inquest have raised significant concerns regarding the care that Keith received, so it is clear that reassurances are needed that lessons have been learned following his death.

“Patients and their families put great faith in the NHS that an appropriate standard of care will be provided, but sadly that was not the case here.” Sinead Rollinson-Hayes - Associate Solicitor

Keith, from Wincobank in Sheffield, had been married to Gillian, 57, for 21 years and leaves behind two sons, one daughter and two grandchildren. 

From the end of August, he started seeking medical advice for an increasing low mood and anxiety. Keith attended A&E at Northern General Hospital on 25 September, 2017, following a visit to his GP that day. He was assessed under the Mental Health Act and detained under Section 2 of the Mental Health Act to Maple Ward at The Longley Centre.

After an initial assessment, staff were to draw up a care plan and detailed risk assessment within 72 hours. However, an internal investigation report by Sheffield Health and Social Care NHS Foundation Trust found no evidence that the plan or risk assessment was updated or discussed with Keith. The investigation also found that the responsible nurses allocated to look after Keith and formulate a care plan were unaware that they had been given this responsibility throughout Keith’s time on the ward.

Keith had been under 10 minute observations following his admission, but this was reduced to every two hours during the day shift, and every 30 minutes during the night shift on 27 September, an inquest at Sheffield’s Medico-Legal Centre was told. However, the inquest heard that there was no evidence to show there was a record for the reduction in observations or any reason recorded as to why.

Keith had mentioned that he did not feel in control of his thoughts and his family raised concerns about his deteriorating condition to staff on the ward.

He was found by a member of staff at around 9.33pm on 29 September. He died the following day after suffering a brain injury through a lack of oxygen.

Reacting to the conclusion of the inquest, his wife Gillian, said: “Less than a year on from losing Keith, the entire family remains completely devastated. It is still very hard to believe he is gone. His death has been made even harder to take knowing that he should have had far better support and care.

“We raised concerns about Keith’s condition and how he appeared to be getting worse, but we feel that our concerns were not listened to. We believe that if they were listened to, then Keith would still be alive today.

“Nothing will ever change what has happened, but we simply want to know that steps have been taken to ensure that no other family faces the ongoing and devastating heartache that we have had to endure. Keith was in an exceptionally vulnerable state and it is vital that no one else ever faces the issues that he did, when it came to his care and support.”

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