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Coroner concludes autistic man's death the result of neglect and gross failure at Bristol hospital

An inquest into the death of a 27-year-old man with autism and learning difficulties has concluded that gross failures in his care at Southmead Hospital in Bristol, including a failure to act on his deteriorating condition, contributed to his death at the hospital on 17 December 2014.

Posted on 28 September 2017

The Coroner’s Court in Flax Bourton, Somerset, heard evidence over three days starting on 25th September 2017 into the death of Nicholas Jones, known to his friends and family as Nick.

In his conclusion delivered on Wednesday 27th September 2017, HM Assistant Coroner Dr Peter Harrowing said that the failure to conduct hourly observations on Nick amounted to a gross failure in nursing care. 

He continued that there was also a gross failure in the level of nursing care provided to Nick on the day of his death. 

Having heard evidence from a senior nurse on the ward, Mr Rogel Bolivar, Dr Harrowing stated that he intended to report Mr Bolivar to the Nursing & Midwifery Council (NMC). 

Dr Harrowing stated that that society expects healthcare professionals to act with honesty and integrity and that he didn’t consider that Mr Bolivar had acted with the necessary honesty and integrity as required of a registered nurse in the UK.

HM Assistant Coroner Dr Harrowing went on to conclude that Nick’s death was contributed to by neglect, meaning that had these gross failures not occurred, he believed Nick’s deterioration would have been noticed and acted upon, and Nick would not have died when he did.

Nick, who had been diagnosed with autism at the age of three and also suffered from epilepsy and tuberous sclerosis attended Accident and Emergency at Royal United Hospital (RUH) in Bath with a suspected ruptured angiomyolipoma (AML) on his right kidney in November 2014. 

Nick was transferred to Southmead Hospital on 21 November 2014 for surgery where he was admitted to the intensive treatment unit (ITU) where he received one-on-one care in an environment where his complex needs could be catered for.

Despite protestations from the family Nick was moved out of the ITU and onto a Urology ward. His family told the inquest that they were concerned that Nick would find being on a busy ward a frightening experience for him, so he was moved to a side room of his own.

Nick underwent surgery and spent a further period of time on ITU before returning to the Urology ward 34b.
On 6 December 2014 Nick contracted Candida septicaemia and his condition deteriorated. On 17 December 2014, while his mother was visiting him, Nick returned from having an x-ray in an unrousable state. 

In her evidence to the inquest Mrs Jones described Nick as deteriorating in front of her, and described how she spotted that her son was having a cardiac arrest and rang the emergency button. She said she had no choice but to start performing CPR on her son. 

A full crash team arrived within minutes but Nick was unable to breathe independently and, upon advice from the medical team, the family made the painful decision for resuscitation efforts to stop.

The family were later informed that Nick’s medical cause of death was a respiratory and cardiac arrest secondary to mucous plugging. 

Nick’s family told the inquest that they were concerned by the adequacy of the care Nick received on the day of his death.  Mrs Jones, Nick’s mother, told the court:

“It was obvious that Ward 34b were struggling and there was considerable reliance on agency staff, mainly unregistered healthcare assistants, to provide Nick’s 1:1 care. Comments were also made that Nick’s need for 1:1 care had financial implications for the Ward/hospital, which was very unpleasant to hear. I had to continually repeat details about Nick’s medical condition, his needs, his abilities etc. and often left the hospital anxious and frightened that either there was no one available to care for Nick during the night, or whoever was there had no knowledge about him.”

The inquest also heard that the family had made a formal complaint to North Bristol NHS Trust, the Trust responsible for Southmead Hospital, following Nick’s death. 

The family took the opportunity in their complaint to identify four individual staff who they felt had provided excellent care in a period otherwise described by the family in their complaint as “simply the worst moments of our lives”.

Following the conclusion of the inquest Nick’s parents Sue and David Jones, of Corsham, said:

“Our son Nick was just 27 years old when he was admitted into Southmead Hospital. 27 days later he had died in the most tragic and appalling circumstances.

“During his time at Southmead Hospital we continued to voice our grave concerns, to staff, about the care he was receiving.

“We felt the hospital took a hostile approach to us as family members. Some medical staff viewed us as a nuisance rather than accepting that we were experts in understanding Nick’s complex needs and had the skills and experience to alleviate his anxiety.

“We welcome the Coroner’s conclusion as we have always believed things could have been different for Nick had he been given the care needed for someone as vulnerable as him – someone with a severe learning disability who was unable to communicate when he was in pain and distress. 

“Every day we wake up to the realisation that as a family we must carry on without Nick. All we can hope for now is that in some small way his story can help prevent another vulnerable adult, and their family, from ever experiencing what we have been through.”

The lawyer for the family, Merry Varney, from law firm Leigh Day said: 

“The family and I welcome the Coroner’s conclusion that Nick’s death was contributed to by neglect and the recognition that there were gross failings in Nick’s care. Nursing care is always very important but it is even more critical for patients who are unable to communicate their own needs, such as Nick, who was a vulnerable adult entirely reliant on others to provide his care.  

“The family complained to the Trust about the conduct of a senior Nurse during Nick’s admission, while praising excellent staff as well, and the Coroner’s referral of this nurse to the NMC due to concerns about his honesty and integrity is a welcome vindication of their concerns.

“The Trust should now fully reflect on this Conclusion and ensure that all practical steps are taken to prevent another family losing a loved one in similar circumstances, including reporting to NHS England’s Learning Disabilities Mortality Review to ensure any learning is shared across the country.”

Dan Scorer, Head of Policy at the learning disability charity Mencap, said:

“People like Nick who have a learning disability and are unable to communicate with doctors rely on their families and carers to advocate for them and explain how they need to be supported. Families should be respected by all medical staff as experts in the care of their loved one and worked with in partnership so the adjustments needed can be made. The treatment of Nick’s family where they were shut out and their concerns not acted on, have been experienced by many families, with devastating consequences.

“1,200 people with a learning disability die avoidably every year, when high quality healthcare could have saved their lives. The solutions to ending this scandal of avoidable deaths caused by failures in care are well known and there are no excuses for not implementing them. No doctor or nurse should be able to set foot on a ward without having had training on supporting people with a learning disability and their families, and the key laws that they need to abide by.”

The family were represented at the inquest by Leigh Day and Jeremy Hyam QC of One Crown Office Row.