I’m not live tweeting Rachel’s inquest as I didn’t get to speak to her family in advance and don’t have their permission. I do wish to report on what happened in court as I think it’s highly likely it’s of wider relevance and interest to others. Day 1 has just finished and I’ve written over 16,028 words in my notes, I’ll try to capture a few salient points.
The first reflection has to be about Rachel and clearly how loved she was by her family, and her mum, Diana, especially. We heard throughout the day how Rachel was usually happy and singing. Diana described in her statement, read to the court by Senior Coroner for Worcestershire, David Reid that Rachel ‘was a lovely lovely girl’ who enjoyed her life and had a good quality of life. She described how it grieves her that Rachel ‘died for reasons I don’t understand‘.
Rachel’s inquest this week will try to find answers to those questions. Rachel was 49 when she died in November 2017, following a full dental extraction at the end of October.
I attended a pre inquest review hearing into Rachel’s death in August 2019 and at that time the plan had been for the Coroner to sit
with a jury in June 2020. Since then the court has obtained expert evidence and covid happened causing further delay. It also seems that following the court obtaining that expert evidence, the position has changed slightly and some concerns that Rachel’s family had about consent for the removal of all of Rachel’s teeth, and the course of action taken, are now considered to have moved on. There was a final PIR last week, and the Coroner is now sitting without a jury. [Edited: See comment below from the family’s solicitor, I’ve got this wrong, the Coroner was never planning on sitting with a jury, he just had a number of jury inquests to hear before he could make time to hear Rachel’s inquest].
Dr Sarah Foy, who works in the specialist community dental service, was an interested person back in August 2019. Since that PIR it had been agreed that her evidence would be read onto the record under Rule 23, and she is no longer represented at the inquest. Her counsel, Mr Sheldon QC, had sent a letter to the court which the Coroner paraphrased, including:
In essence Mr Sheldon asked for confirmation, he assumes the basis on which it is decided Dr Foy’s evidence can be read is because it is unlikely to be disputed and the Coroner has no reason to doubt its accuracy… therefore no-one considers Dr Foy is someone, who by act or omission, contributed to Rachel’s death.
No one disagreed.
Today in court we heard oral evidence from two nurses and a care worker. The Coroner also read a number of statements onto the record. The statements read to court painted a picture of Rachel having pain from her teeth that was preventing her eating, action was required to be taken. Diana voiced a number of concerns about the possibility of Rachel undergoing a full dental clearance, these were discussed with Dr Foy on more than one occasion, before they both decided that if on examination (once under anaesthetic) it was decided that Rachel’s teeth were not viable they would be removed.
We heard how on Friday 26 October 2018, Sheila Taylor, a care worker from Pirton Grange where Rachel lived, drove her, accompanied by her mother, to the Dental Treatment Centre in Kidderminster for her surgery. Rachel was given a general anaesthetic nasally, she was taken into theatre and the surgery was straight forward, lasting only 20 minutes. On examination it was found that many of Rachel’s teeth were damaged, some were just fragments, all 19 teeth/fragments were removed using forceps. From a dental perspective it was uncomplicated and no surgical intervention was required.
Once into recovery Rachel’s temperature was low, although it was reported that she often had a low temperature and felt cold. A ‘bear hugger’, a forced air warming blanket, was used to raise Rachel’s temperature and she was returned to the ward from recovery with it still in place. Rachel reached the ward at approximately 5pm and was alert, singing, had eaten yoghurt and drunk some water before her discharge back to Pirton Grange care home at 7pm that evening.
What it appears is in dispute is what advice was, or was not, given to Rachel’s care worker, Sheila Taylor, and her care home, on her discharge. Sheila Taylor described briefly glancing at the paperwork she was given, a discharge information sheet and a letter for Rachel’s doctor. She recalled:
I asked the nurse if she had the documentation I brought in with me. She said there wasn’t any paperwork, so I insisted there was some MAR charts and Rachel’s hospital passport and I couldn’t go until it was given back to me. So the nurse went to have a look for it.
Sheila says she was given the paperwork and they left. When the Coroner probed whether any advice was given about looking after Rachel after her surgery Sheila Taylor responded ‘No, nothing was said, as soon as we had the paperwork we went then’. On questioning by the Coroner she said she didn’t ask any questions about how Rachel should be cared for following the surgery, and on their return to the care home she passed Rachel over to a colleague to return her to her room, and she passed all the paperwork over to the nurse at the care home.
Sheila reported how Diana travelled in the back with Rachel on the journey home and Rachel was alert and singing, although at one point ‘she did have a bit of a cough and spurted out a bit of blood but it wasn’t much‘. Probing from the Coroner revealed that the care worker didn’t mention this when handing Rachel back to staff after the trip home.
Lizanne Gumbel QC, counsel for the family, probed what training Sheila Taylor had before starting work at Pirton Grange, we heard that previously she’d worked as an office clerk and a forklift truck operator. Sheila said she’d done some e-learning and shadowed a senior support worker for two weeks. She’s received no training in relation to medical observations, or anaesthesia, it was anticipated that was the responsibility of nursing staff. Ms Gumbel asked if she’d noticed a change in Rachel on the journey home, stating that Diana had ‘described how she seemed to go to sleep and was slumped in her wheelchair‘. Sheila didn’t remember that, claiming that Rachel was awake but ‘she just went quiet‘. She claimed she didn’t receive any advice from the hospital in relation to coughing up blood.
Next we heard evidence from Staff Nurse Kate Griffiths from the Kidderminster Treatment Centre. She described how there was a process of nurse-led discharge in place and on prompting confirmed she’d made the decision to discharge Rachel that evening. The Coroner checked and Rachel’s last temperature prior to discharge was 35.1. He probed whether that was in a normal range, Kate Griffiths explained how it was not in the normal range and gave a MEWS score (early warning system) of 1. The Coroner asked whether that required any action and she answered that she didn’t consider it did as it was rising (from 34.6 in recovery).
The Coroner checked that this was still a whole degree lower than on admission [it was] and was not in the normal range [it wasn’t] and the warming device, the bear hugger was not going home with Rachel [it wasn’t] but Staff Nurse Griffiths was not concerned.
The Coroner asked what paperwork Rachel would have been discharged with and Staff Nurse Griffiths was insistent that:
every time we discharge a patient after a general anaesthetic, we give this information [Important information after your surgery leaflet]; everyone has a GP letter and we have different leaflet depending on what procedure so we would have given a dental leaflet.
Despite her certainty she did admit she could not remember in this particular case; citing it was such a long time ago (which it was,
over three years ago *Edited Rachel actually died a little over two years ago). Unfortunately it appears that the Trust have not been able to locate a copy of this dental leaflet and it is no longer available.
Counsel for the family asked Staff Nurse Griffiths who was present when she completed the discharge information leaflet, was it just Rachel and her mother, or was the care worker present. She confirmed that the discharge information would have been completed at the nurse’s station when the patient came up from theatre, so no-one would be present, but she was certain she’d have shown it to them and talked them through it before they left.
Later when questioned by Mr Ley Morgan, counsel for the care provider, Kate Griffiths was equally insistent on her practice, stating:
We discharge patients day after day, we have tens of patients a day. We always give out the same information and the same leaflets so I’ve no reason to believe I did anything different on that day.
When pressed by Mr Ley-Morgan on whether she remembered this specific handover she answer that a lot of time had passed since the event. He pointed out that her statement written just a couple of months after Rachel’s operation had failed to mention that she’d had to go search for Rachel’s documentation bought in from the home. She said she’d not felt it was significant for this statement.
The final witness to give oral evidence was Miss Alison Truman, a clinical advisor (nurse) for the 111 service. We heard a lot in Ms Truman’s evidence about clinician to clinician conversations. This related to a call that the nurse at Pirton Grange had made to 111 the day after Rachel’s surgery.
The person who took the call triaged the situation as urgent and requiring a call back within half an hour, by 19:44. This call wasn’t made until 20:34, an hour and twenty minutes after the initial contact was made. We heard lots about Rachel being a ‘special needs’ patient.
We heard that the information that was available to Alison Truman before she made her call back was ‘all teeth removed, still bleeding from mouth, learning difficulties, may have swallowed blood’. She told the Coroner how she advised the nurse on how to stop the bleeding (apply pressure with gauze) and advised against using suction for fear could disturb clots. She asked about her breathing and had no concerns. She claimed there was no urgency in the Pirton Grange nurses’s voice.
On questioning from the Coroner as to why she didn’t ask more questions, or ask about physiological observations, she responded:
….I’d like to assume they’d been a assessment of her consciousness level and that she was sleepy and not falling into a unconscious level
The Coroner interjected: Ms Truman you say assume, why not ask?
Because she’s a healthcare professional, she’s a nurse…
Later when the Coroner asked what advice she gave, she said she provided advise about stemming the bleeding, avoiding suction and finished with the statement:
I’d assume from a nurse to nurse point of view, if this is all a bit hard call us back and we’ll give you more assistance
Ms Gumbel asked a number of questions before asking:
What’s the point of providing an out of hours service to provide advice if you’re assuming a nurse in a care home knows as much as you do? Any concerns that she’d not been alert since Friday evening you’re not ascertaining, you’re not adding anything?
Nurse Truman provided an answer about how she’d reflected on her practice, she was a mother, countless times she’d questioned whether she could have assessed differently but she settled on the fact she wasn’t given information that raised any red flags.
Ms Gumbel shared that there had been a Root Cause Analysis into the 111 service response that included the criticism that there was ‘insufficient inquiry into the symptoms given’ and asked Nurse Truman whether she agreed with the criticism of her approach.
Ms Gumbel had to ask four times before eventually getting an answer:
I’m not having words put into my mouth, no…. if I wanted to say could I wish I’d done things differently, that’s different, yes I do, at the time I went with the information I was given.
The Coroner also raised the criticism in the RCA that there was no three phase safety netting given by Nurse Truman. Something she again did not agree with.
Finally for Day One the Coroner read the evidence of Diana Johnston and a number of care workers from Pirton Grange onto the record. A picture of Rachel not really rousing from her anaesthetic after becoming drowsy on the trip home emerged. Her mother described how she ‘kissed her and said mummy will see you first thing tomorrow’.
Her mother called first thing the next day, the Saturday, and had been told Rachel had been bleeding through the night. She went straight to the home and described how she found Rachel:
She was slumped to one side, she wasn’t talking, she didn’t register my presence. Her tongue was swollen and sticking out her mouth.
Her statement described how she sat with Rachel until 1:30 or 2 in the afternoon.
This seemed wrong to me, I asked the home to call a doctor, they said they would but would be in a little while… That evening I called the home and asked what the doctor said. They said the doctor hadn’t come out, they’d rang 111 and they’d said keep fluids up.
The next morning Diana called the home and was advised the home were worried about Rachel. Before she’d got there she got a call to say an ambulance had been called and she met them at the hospital.
Diana’s statement described ‘it was like she wasn’t my Rachel any more… she was fighting for her life‘. Rachel’s family were advised she’d need to go onto life support, she never recovered, having discussed with family members a week after Rachel was admitted to hospital Diana rang the Trust to let them know they could remove Rachel’s life support. After permission was given Rachel was discharged back to Pirton Grange with palliative care support so that she could die in familiar surroundings with her things around her. Diana stated:
‘I was horrified it took so long. I stayed with my daughter the whole time from when they took her off life support until she died. My daughter was a lovely lovely girl, she enjoyed her life, she had a quality of life’.
The inquest continues tomorrow morning.