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Peggy Copeman: A much loved Norfolk woman who died because of the beds crisis at NSFT

(written with permission of Peggy Copeman’s family)

The CCTV footage of Peggy Copeman being wheeled down the hospital corridor as she left Cygnet hospital can be viewed in this article Peggy is slumped in her wheelchair, her belongings in a bin liner. 

When Premier Rescue Ambulance Service staff asked about Peggy’s unresponsiveness a  member of Cygnet staff told the “ambulance” staff that she was “acting out” and “pretending” to be asleep, and that she would wake up on the journey and likely be verbally and physically aggressive. The term ‘acting up’ and ‘acting out’ was repeated by the member of staff in her evidence at the inquest.

Peggy never woke up. For a significant amount of time (the inquest could not determine due to conflicting witness statements) but possibly two hours or more Peggy was in respiratory distress.

Only one out of the three staff had had basic life support training so no one sat beside Peggy recognised the signs of respiratory distress and mistook it for snoring. The noise that she was making was at one point so loud and unusual that the driver thought there was something mechanically wrong with the van.

When they finally pulled over on the hard shoulder of the M11 in Essex they first telephoned their manager, then Cygnet, before finally calling 999. They did not lay Peggy down to attempt CPR but left her upright in the car seat. The paramedics were shocked by what they saw on arrival. The expert witness statement from a specialist cardiologist was that Peggy had died  whilst sat between two staff who did not notice her respiratory distress. They were not trained to. 

It emerged during evidence that one of the escorts was in fact only working a ‘shadowing’ shift having never worked in health or social care and having received no training. She should have been supernumary. (No doubt PRAS charged NSFT for two escorts & a driver).

But let’s not forget that what started off this shameful sequence of events was that there were no older peoples beds in Norfolk. 

On Thursday 12 December Peggy was transported 280 miles to Taunton in Somerset. Her first ever time out of Norfolk in her 81 years of life. Imagine how frightened she must have been. It was difficult to get a physical health assessment as Peggy was resistant to this (she was in great distress and confusion) so a decision was made to send her without one. She had not been eating or drinking.

Transport was requested to convey her on a stretcher with leg straps for safety, however a minibus was sent so she was transported seated in her wheelchair locked to the floor. She did not eat on the 6 hour journey and it was not documented whether she had any fluids. It is not documented if she has any fluids during Thursday evening at Cygnet.

On Friday it was apparent a bed would be available in Norfolk on Monday.  Her care coordinator raised concern about another long journey so soon when she was so unwell.

Peggy continued to eat only a few mouthfuls of food each day, and drink between 350mls and 500mls of fluid per day (the minimum that should be aimed for is 1000mls).

Witnesses at the inquest cited Peggy’s fluid chart detail as showing:
– Pre-admission reported as not eating or drinking much at all
– Journey down on 12th – no food taken,  fluids not recorded
– During stay at Cygnet:12th – no fluids recorded, 13th- 500mls, 14th – 400mls 15th – 500mls, 16th – 100mls (prior to leaving at 10am). None during journey. 
So potentially 1.5 litres of fluid since leaving Norfolk. 

On Saturday she was diagnosed with a UTI and a course of anti-biotics started. Peggy’s family raised objections to her return so soon while she was so poorly. They wanted the anti-biotics to be given a chance to work.

Only one nurse (who was covering two wards as no registered nurse on Peggy’s ward turned up to work on Sunday) questioned whether it might be a delirium related to a UTI rather than a relapse of psychosis. 

The CCTV linked in this article shows how Peggy was when leaving Cygnet for the 280 mile journey to the Julian hospital.  It speaks for itself.
Peggy was not given a physical examination by a doctor prior to leaving Cygnet. They did not attempt one because they presumed she would decline as she had done on previous days. However the inquest heard that that morning Peggy had co-operated with personal care and getting dressed. The doctor instead viewed Peggy through the window of the nursing office and deemed, at an unknown distance, that she was “physically stable” and described her as being sat upright in her wheelchair and eyes as being “bright and alert”. This was some time between 9 & 9.30am. 

The CCTV was approximately 40 minutes later. The CCTV is not consistent with the doctor’s description of her a short time earlier. So why was no action taken to this drastic change in presentation? We think the shameful comments made by staff about Peggy ‘acting out’ might explain the non-action on their part.

The expert witness view was that Peggy was at high risk of a heart attack as she had unknown ischaemic heart disease.

There is no escaping the fact though that if Peggy had been in Norfolk either at her care home or at the Julian hospital she would have been surrounded by staff trained to recognise respiratory distress and intervene to possibly avoid respiratory and then cardiac arrest. Most importantly her family would have been able to see Peggy.

The 999 call was made at 2.27pm. The family were phoning round each organisation involved being fobbed off,  and frantically calling all local hospitals they could google search around the area they thought she might be. They were not informed of Peggy’s death until after 7pm.

The coroners court had covid safety measures in place to allow people to attend in person. Every organisation declined to attend in person citing covid as the reason.  Given the nature of everyone’s work they are likely doing lateral flow testing twice a week and double vaccinated. No one had the decency to come and look the family in the face. Nick and Maxine have carried themselves with dignity throughout. Yes they are angry and who can blame them. 

The risk to patients of no beds and long journeys has been known for such a long time before Peggy needed crisis care. The evidence this week must have been heartbreaking and at times enraging to hear.

We are pleased to learn that the Coroner raised concern about the disrespectful language used to describe Peggy and commented that it showed a lack of understanding of mental ill-health.

The coroner made a second Prevention of Future Deaths report to the ‘ambulance’ service as proper staff training and policies and procedures are not yet in place despite 18 months having passed and an earlier PFD report issued prior to the inquest. We await with interest if any other organisation gets issued with a PFD notice specifically about the lack of local beds as the coroner said this concerned her greatly.

The two big organisations who were lawyered up – Cygnet & NSFT – got off lightly. It seems all you have to do is say “we’ve done our own root cause analysis and implemented the findings” and that’s ok, without too much scrutiny of whether anything has actually changed.

A recording of the report by Nikki Fox on BBC’s Look East sums up what happened:

We will be watching, and commenting, about whether anything has improved and changed at NSFT in the coming days and weeks.

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