BBC News: Richard Handley: ‘Gross failures’ in constipation death

BBC News reports:

A “missed opportunity” for potentially life-saving treatment contributed to the death of a man from constipation complications, an inquest has found.

Richard Handley, 33, who had Down’s syndrome, died at Ipswich Hospital on 17 November 2012.

Some 10kg (22lb) of faeces was removed from his body two days before.

Coroner Dr Peter Dean said there were “gross failures” in spotting Mr Handley was in a critical state after the surgery.

After an 11-day inquest at Ipswich Coroners’ Court, Dr Dean said an overall care co-ordinator “would have prevented this from happening” as there were a number of agencies involved in looking after Mr Handley.

Mr Handley’s mother Sheila, who gave evidence during the inquest, said outside court she was “disappointed” after the coroner’s verdict.

“With hearing about the gross failures identified and missed opportunities spoken of I find it very hard to understand how the coroner didn’t feel able to use the word ‘neglect’ in his conclusion,” she said.

“It feels to me, having heard all the evidence, that the level of the failures was such that Richard died because he was neglected. He wasn’t given the care he needed to keep him safe.”

A record of the proceeding are available on the excellent Richard Handley Inquest Twittter account.

Richard Handley was just 33 years old when he died.

Beyond Richard Handley’s unnecessary death, what are the wider lessons to be learned?

The Suffolk Safeguarding Adults Board’s Serious Case Review into the death of Richard Handley (using the pseudonym James in the link) states:

[Richard Handley] was known to Suffolk Mental Health Partnership during 1998. This merged with Norfolk and Waveney Mental Health Partnership during January 2012 and became the Norfolk and Suffolk NHS Foundation Trust. James was seen by the Community Learning Disabilities Team from 1999 to 2003 following the Care Programme Approach (CPA). His care coordinator was a Community LD Nurse. Between 2003 and 2008 [Richard Handley] was seen by a consultant psychiatrist. From 2008, the CPA was re-launched as Non CPA and [Richard Handley] remained on this pathway until his death. The Non CPA meant that [Richard Handley] did not have a formal community care coordinator. Also, it meant that he was not deemed to have complex or high risk needs and could therefore be managed by the Consultant Psychiatrist as he was thought to need medical/ medication review. His social care and primary health care needs were provided and monitored outside of the mental health trust.

How many times have we heard about inappropriate discharges from, or failure to adopt, Care Programme Approach (CPA) and a lack of care plans and care co-ordinators at Norfolk and Suffolk NHS Foundation Trust (NSFT)?

We know that the cuts at NSFT during the radical redesign were so savage that patients were discharged from CPA simply because NSFT no longer had enough suitably-qualified Band 6 nurses, having paid them to leave or down-banded them.

The Care Quality Commission has condemned the lack of care plans at NSFT for years. The management of NSFT’s typically incompetent and bureaucratic response was to create internal working and implementation groups which met for years but did little to improve the situation on the front line.

Julie Cave, chief executive of Norfolk and Suffolk NHS Foundation Trust (NSFT), said it “fully accepts” the conclusions of the coroner.

She added: “Since the publication of a serious case review in 2015, NSFT has made significant improvements to the services we provide to people with learning disabilities who also experience mental illness.”

How many times have we been promised ‘significant improvements’? Again and again and again and again.

How many more deaths?

Click on the image below to read the article in full on the BBC News website: