Inquest finds failures in care by Prospect Park Hospital led to the death of Anne Roberts

The inquest was held over four days at Reading Town Hall in front of a jury which returned a narrative conclusion on Friday 14 September 2018. The conclusion stated that the Speech and Language Therapist’s  (SALT) guidelines in relation to Anne’s diet were not adequately passed on to staff on her ward and handover notes were inadequately detailed.
 
The jury also concluded that the food given to her on the day of her death, which resulted in her choking, was unsuitable and did not meet the SALT guidelines of a soft diet. Anne had been placed on a soft food diet two days before her death. The jury added that the actions of staff were inadequate to minimise the risk of Anne choking.
 
The Coroner announced that he intended to issue a Prevention of Future Deaths (PFD) report in due course.
 
Anne died on 28 September 2017 while in the care of Prospect Park Hospital in Reading as a detained mental health patient. She choked to death after eating a piece of cake, only six days after a previous choking incident at the hospital.
 
Anne was admitted to Prospect Park Hospital in August 2017 as an informal inpatient after a decline in her mental and physical health and was later detained under the Mental Health Act. She was put on two-to-one care at all times to keep her safe. 
 
Anne’s daughter Christie Dyball told the inquest that she was informed that her mum had died due to choking and was given no reason to believe that it could have been preventable. However, some four months later she found out from a friend that there had been previous choking deaths at the hospital and a CQC report from December 2017 which referred to her mum’s death.
  
Anne’s family’s grief and distress was further compounded before the inquest when they were told there was no family room for them to use as a private space during the inquest. When Christie’s solicitor Merry Varney wrote to the Coroner and the Reading Borough Council to ask for the use of a family room for her client she was told that there would be a charge of £1000 to use one of the rooms in the town hall. This was later reduced to £324 which Christie had to pay before the inquest. The Legal Aid Agency, who funded Christie’s case, refused to cover the room charge, stating it was the responsibility of the coroner.
 
Christie has made a formal complaint to the Senior Coroner for Berkshire regarding the charge for a room which was requested in order to provide a place for solace for the family during the inquest and also to receive confidential legal advice. 
 
Christie, of Cromer, Norfolk, said:
 
“My family and I are devastated by mum’s death and we want to ensure that any failings in her care are identified and steps taken to ensure that other patients are better protected in the future.
 
“Mum was so unwell at the time of her death, she was wholly reliant on staff at Prospect Park. Had the hospital and its staff better understood and managed her need for a soft diet, we believe that mum would have had the opportunity to get better and could have returned to living in the community, as she had done for many decades beforehand.”
 
Merry Varney, partner at law firm Leigh Day, added: 
 
“The recognition by the jury of the multiple failings in Anne’s care is welcome, particularly given the additional stresses placed on her daughter while trying to participate effectively in this Inquest: from delays in a decision by the Legal Aid Agency to the charge being levied by Reading Council for the use of a room during this distressing process.
 
“Sadly neither Christie’s experience as a bereaved family member nor Anne’s experience as someone needing physical healthcare in a psychiatric hospital but not receiving it are unique and I hope the changes implemented by the Trust are shared widely to ensure better care for other vulnerable people across the country.”
 
Christie was represented at the Inquest by Merry Varney and Sophie Wells of Leigh Day and Paul Reynolds of One Crown Office Row.