The final evidence was heard in Rachel Johnston’s inquest today.

There was a discussion before we heard from the expert witness about how to handle the evidence of the Registered Manager at Pirton Grange, who’s evidence was part heard on Tuesday. She’d described Rachel as ‘a personality that brightened up any room… a joy to be around’.

The exchange I found most noteworthy in the evidence she gave was the following:

Coroner: When were you were first made aware Rachel had been taken to hospital on Sunday 28^th ?

Approximately 13:30 on Sunday. I got a telephone call from Nurse Gill Bennett to be told they’d phoned 999 and two ambulances and a helicopter were coming. I was quite shocked because I didn’t know anything about her return from hospital.

Coroner: Were you shocked you hadn’t been kept abreast of affairs before that? Would you expect to have been told 111 was called the night before?

Absolutely, I was shocked I didn’t know she’d deteriorated on the Saturday, to be told she was deteriorating and going to hospital. I still can’t understand that to be honest.

The registered manager’s evidence is part heard and she is unable to return this week. Following discussion between the Coroner and the interested persons it was agreed that she will return to court to give evidence in relation to a Prevention of Future Death report at a later date. That in itself would not stop the Coroner concluding the inquest as parties were content with his suggestion:

Coroner: does anyone disagree with the suggestion that Ms C has given sufficient evidence that would enable me to reach conclusions about the evidence itself, and all that remains is her evidence and further questioning that goes to PFD report?

Once that was agreed the coroner read two further statements onto the record under Rule 23. One was from a Pirton Grange support worker and the second was from the pathologist.

Coroner: before I do that [read the pathologists’s report] Mrs Johnston I’m going to address you directly if I may. I’m not going to deal in great detail with Professor West’s report, only his conclusions.

It is always an upsetting thought to imagine a loved one undergoing an examination such as this… I wanted to reassure you that Professor West is an extremely experienced pathologist and I do know he’d have treated Rachel with the dignity and respect that she deserved, and I hope that’s some small comfort to you in the circumstances.

Professor West conducted Rachel’s post mortem on Tuesday 20 November 2018. The histology section of his report recorded:

‘patchy bronco pneumonia consistent with the clinical impression of aspiration… blood however is not conspicuous

The Coroner continued reading from the report.

‘He concluded that Rachel’s cause of death was

1a cerebral hypoxia

1b aspiration pneumonia

1c dental extractions

Against a background of

2 hydrocephalus and epilepsy following childhood meningitis’.

Later the Coroner discussed the finding that blood was not conspicuous in Rachel’s lungs at her post mortem with the expert witness, asking about the histological appearance not suggesting major aspiration of blood and what that told us about aspiration in this case.

The expert, Dr Christopher Danbury, explained he felt this was not surprising given Rachel’s admission to ICU prior to her death, describing how:

they’d be a great effort by ICU nurses to clear her lungs…. my goal as an intensivist will be to remove as many abnormal secretions from her lungs, including blood.

When asked by the Coroner whether he was satisfied that the aspiration in this case was of blood as opposed to anything else, he responded that Rachel must have aspirated blood as she was still actively bleeding, and blood was the only thing different that weekend, to the previous one.

Dr Danbury is an Intensive Care Physician at University Hospital Southampton. He told the court he’d moved there in December 2020, after 18 years at the Royal Berkshire Hospital. Dr Danbury answered questions simply and clearly, and showed a respect for Rachel that was noteworthy.

He explained his background and qualifications and talked the court through the anaesthesia given to Rachel, both general and local, and what impact it were likely to have, and how long it might be expected to take to wear off. He was of the view that the duration of Rachel’s surgery was not excessive, the anaesthesia used was appropriate and he had ‘no hesitation in saying the drugs used in the general anaesthetic would have worn off by 7 o’clock that evening’.

He also felt the dose of local anaesthetic used was well within the toxic level and there was ‘no question a safe amount was administered’. He was similarly confident that the local anaesthetic would have worn off prior to Rachel being discharged home.

Dr Danbury also ruled out any question of Rachel suffering an allergic reaction that caused her tongue to swell as that would occur immediately when administered. The fact Rachel was awake, had eaten and drunk and was singing when she left hospital ‘leads me to think she was not aspirating at that time and had pretty much recovered from the effects of the anaesthetic’.

Dr Danbury confirmed he’d expect a trained nurse to notice that she’d returned to normal level of consciousness, then had progressed to having an altered level of consciousness. He felt on the balance of probabilities that Rachel started to become hypoxic on the Saturday afternoon and when asked by the Coroner whether he’d expect nursing staff to pick up on any signs that Rachel was becoming progressively hypoxic, he responded:

Yes. A trained member of nursing staff will see a hypoxic patient becoming blue, this is part of basic training for nursing and medical staff. By the time saturation is in the mid 80s she’d become blue, by time it was getting down to 60s some of her extremities would be almost navy blue. Yes a trained member of staff should have picked that up.

He noted his surprise no physiological observations of Rachel were recorded bar the two measures taken at 7pm on Saturday before calling 111. When the Coroner asked what would make him surprised he responded:

If you’re going to a nursing home, a home that has got trained members of nursing staff in attendance; and somebody has just had an operation and they’re not able to communicate what’s happening to them, you have to assume a proportion of patients that come back from an operation will have some degree of problems, some minor, some major, and the only way you can assess that is by doing physiological observations on a regular basis.

If someone is stable and hasn’t been to hospital, then you could do them on an ad hoc basis. If someone has just had an operation, you would expect regular observations until everyone is happy that she is stable….

You can debate the frequency of those observations, whether every 4 hours, or even 8 hourly, but you would expect them to be done until the patient becomes stable.

I have to admit I’m surprised they weren’t done. It certainly has affected by thoughts about people going back to care homes following acute procedures in hospital. I’d not considered before, I rather assumed some base level observations were done.

When the Coroner asked whether he agreed or disagreed with the suggestion that observations for Rachel in this situation was basic medical care, Dr Danbury was empathic:

Yes, it is basic medical care.

Coroner: can one reasonably take the view at any point between when Rachel was returned back to the hospital [on Sunday]… take the view Rachel had become sufficiently stable observations were no longer required?

No quite the reverse. She’d become less stable, her chest sounds more wheezy, absolutely not stable.

Asked how serious a failure in medical care the observations not being carried out was, after a caveat about him being a hospital and not community doctor, he responded:

I would expect a level of measurement of basic physiological parameters to be done as a matter of routine and I think the failure to do basic observations when somebody has had an operation the day before, and who can’t communicate things are back to normal, falls pretty far short from what I’d expect from a competent medically trained individual.

The Coroner checked he’d include a trained nurse in that, he would.

When questioned about Rachel’s hypoxia [the brain being starved of oxygen] and whether a sudden event could have caused it, Dr Danbury was of the view that was not likely.

If I took a fit healthy person and suddenly made their oxygen saturations 63% they would most likely have a cardiac or respiratory arrest shortly thereafter, but the body is very good at compensating over time. So if changes occur slowly, particularly a young lady like Rachel, would compensate for those changes until it reached a point where it became unsurvivable.

She was getting close to having respiratory arrest when paramedics got there… she didn’t have one, but by that point there was very significant end organ damage, shown with CT scan and subsequent EEG during her stay on intensive care.

He explained how there was no prospect of reversing that damage by the time she presented to hospital on the second occasion. When asked by the Coroner whether it would have made a difference if Rachel was readmitted to hospital earlier on Sunday morning he acknowledged it was a hard question to answer but he felt:

On the balance of probabilities by Sunday she’d suffered some significant brain injury and I think realistically to return her to her normal state of cognition and function she should have been admitted to hospital on Saturday night, 12hrs before. Saturday evening realistically at or around the time of the 111 call .

Coroner: if she had been admitted on Saturday evening would there have been a chance she’d have survived this episode?

Yes, very much so

Coroner: do you put it as high as probably would have survived this episode?

Yes.

The final evidence we heard was from Mr Twohig, a consultant oral maxillofacial surgeon at Worcester Acute Hospital who had conducted the comprehensive Level 2 investigation on behalf of the Trust. The Trust investigation identified that the information leaflet in the context of patients with a learning disability could have been improved upon, however he felt it was a ‘reasonable expectation that she was going to a safe environment, in a nursing home’.

The other aspect highlighted by the report is that if Rachel had returned home into the community, to her parents for example, they would have received a follow up call the next day from the Kidderminster Treatment Centre to check how she was doing. Again this was not felt necessary as she was returned to a nursing home and was being looked after by qualified nurses.

Following Mr Twohigs evidence there was a brief discussion about the law; all parties were agreed in respect of the law that the Coroner had to consider regarding neglect. Mr Ley-Morgan, Serjeant Inn counsel for Pirton Grange took the opportunity to make the following clear to the Coroner:

I am on instructions not to seek to dissuade you… I’m not going to suggest that you should not be considering neglect, there is clearly evidence on which you should be considering it. Those are all the submissions I intend to make.

Mr Connolly, Park Square counsel for the Out of Hours Service agreed with the Coroner entirely on the law, but in relation to his client and their witness invited the Coroner to carefully consider whether the circumstances of that consultation ‘not withstanding failures that might be apparent, whether you can be satisfied they’d be considered gross failures’.

The Coroner is now considering the evidence and we’ll return to court in an hour, at 3pm.