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Inquest verdict into unexpected death of a man with severe learning disabilities

The jury has reached its decision at the inquest into the death of Kyle Flack

Posted on 20 July 2009

The two week inquest into the unexpected death of Kyle Flack, a young man with severe learning disabilities, at Basildon Hospital, ended today at Chelmsford County Hall. Kyle died in October 2006 from asphyxiation after his head became wedged in the metal frame of his hospital bed. The Coroner appointed a jury to be present at the inquest to hear the evidence. Appointing a jury was a mandatory requirement as the death was reported to the Health & Safety Executive at the time.
Kyle Flack was a young man with severe and profound learning disabilities. He was blind, deaf, born with cerebral palsy brain damage and a quadriplegic. Whilst he had no language he was able to communicate by making different noises to express feelings including happiness and pain.
On 10th October 2006, Kyle became ill and was taken to A&E at Basildon Hospital. He was then moved to a surgical assessment ward where his mother told staff that he would need bumpers for the sides of his bed. When Mrs Flack visited Kyle the same evening some children’s bumpers were on the bed, but they did not fit and were not fixed in position. Kyle was placed in a four bed bay on the ward. That night an extra nurse was brought in to provide Kyle with one-to-one care.
The following day Kyle was moved to a new ward and placed in a single room. Kyle’s bed was still fitted with child bumpers and at least one member of staff caring for Kyle was not aware he was deaf. Mrs Flack had not spoken to a doctor or nurse about Kyle’s needs since transfer to the new ward and Kyle was taken off one-to-one care without his family or carers being informed.
On 12th October 2006, Mrs Flack was informed by two hospital staff, one a registrar, that Kyle had died. Mrs Flack immediately asked to see her son and noticed that he had an indentation across his forehead and that his face was highly coloured. Two members of the hospital staff visited Mrs Flack at home later that day and told her that Kyle’s head had become lodged between the metal frame of the bed which would explain the marks on his face.
Mrs Flack was told that Kyle had died from asphyxiation. He was found sideways across the bed, with his head between the cot sides.
Investigation and inquest 
The police were informed about the circumstances of Kyle’s death and looked at the case in detail to see if it was possible to bring a charge of gross negligence amounting to manslaughter and it was decided that they should refer the case to the Coroner. The Health and Safety Executive have also become involved in the case. The inquest into Kyle’s death lasted for two weeks. MENCAP, whose campaign Death by Indifference highlights similar cases, also had a representative attending the inquest.

The findings at the inquest 
During the two week inquest the jury heard evidence from the Trust’s staff including the nursing staff who were caring for Kyle during his final admission to hospital, the Deputy Director of Nursing and the Chief Executive Officer of the Trust. 
The jury heard over the course of the inquest how Kyle had been found with his head caught in the cot sides during a previous admission to hospital in July 2005, a year preceding his death. An Incident Report Form was completed stating this incident was “likely” to happen again. However, this form was not seen by the staff looking after Kyle during his final admission in October 2006. 
Furthermore, the jury heard how a member of staff witnessed Kyle’s tendency to move his head towards the cot rails and even put his head through the rails on the first day of his admission in October 2006 but failed to record this in his notes. 
Cot rail “bumpers” were placed on the rails of Kyle’s bed, however the wrong type of bumpers were used (paediatric bumpers as opposed to adult bumpers) and these bumpers were not secured to the bed. 
On the following day, the day of Kyle’s death, it was noted by the member of staff caring for him that Kyle was able to move himself round in bed and move his head towards the cot sides as the member of staff had to reposition Kyle six hours before his death. Just two hours before his death it took three members of staff to reposition Kyle as he had once again managed to move his head towards the bars and begin to get his head between the mattress and cot sides. 
Although Kyle was entirely dependent on the staff caring for him at Basildon Hospital, the evidence before the jury was that not one member of staff caring for Kyle had considered it a risk that Kyle might trap his head between the rails. 
The independent nursing expert appointed by the Coroner to provide a report on Kyle’s care during his stay at Basildon hospital gave evidence that, in her professional opinion, Kyle should have received one-to-one care throughout his entire admission from 10 October 2006 onwards. Moreover, the nursing expert was of the opinion that all staff caring for Kyle should have been immediately aware of Kyle’s disabilities, in particular, his communication difficulties.

The Verdict 
The jury gave their verdict on the afternoon of Monday 20 July 2009 finding that the circumstances leading to the death were:
  • Inadequate risk assessments and reassessment of Kyle;
  • The level of supervision had been inadequate for Kyle’s complex needs;
  • There had been poor record keeping on behalf of the Trust;
  • Ineffective cascading of information which failed to support staff at grass roots level;
  • There had been insufficient training on the proper use of cot sides and bumpers;
  • There had been a failure to easily access the previous incident report form. 
  • The cause of death was contributed to by neglect.
Mrs Flack said, “Kyle had very complex needs, yet he was left for long periods of time on his own and unable to communicate. When loved ones go in to hospital you trust the staff to do their job; part of that is to keep loved ones safe. This did not happen.
Although the nurses had a duty of care, the standards were so poor: there was poor written documentation, little verbal communication between the staff and our family, a lack of training of staff in learning disabilities, poor leadership and a general lack of common sense. These factors together with neglect all impacted on the care of our son and resulted in his unnecessary death. The independent nursing report highlighted the failings and found that the standard of care was not of a reasonably competent standard.
The verdict today is a clear message to Basildon Hospital and will hopefully make the staff think and learn lessons. But for us it comes at the expense of our darling son’s life. Our son died alone in a horrible situation which could have been avoided just by simple actions from the staff. The Trust has a very long way to go to improve standards and to learn how to care for the most vulnerable people in our society.
Despite the challenges Kyle faced, he led a happy and fulfilled life. Our family miss a much loved person who, for all his disabilities, had an infectious laugh, a unique personality and a charisma that drew people to him. He loved the wind on his face, loved being pushed over cobblestones and laughed from the moment he woke to the moment he went to sleep. Our heartache will remain forever.”
Frances Swaine, head of the human rights at law firm Leigh Day & Co said:
“We are glad to see that the jury considered all the circumstances leading to Kyle’s sad death and returned a verdict that listed the many areas of concern highlighting how he  was failed by those caring for him . This was a clearly avoidable death that has left Kyle’s family devastated. Yet again a young person with learning disabilities and no communication skills appears to have been de-humanised and treated as a problem to be brushed away, rather than as a human being capable of feeling pain and fear."

Mrs Flack instructed Leigh Day & Co solicitors and was represented by her barrister, Abhijeet Mukherjee, of Outer Temple Chambers, throughout the inquest.  Mrs Flack received exceptional funding through the Legal Services Commission, authorised by the Ministry of Justice.  Leigh Day & Co and their client wish to thank the Legal Services Commission for this support as without this funding Mrs Flack would have been without representation.

For more information please contact Frances Swaine on 020 7650 1200.