This afternoon, Senior Coroner for Worcestershire David Reid found that Rachel Johnston died as a result of complications of necessary surgery, to which neglect contributed.

In the summing up of his evidence the Coroner said:

Despite all the challenges which Rachel had to face she was a lively and happy woman who loved music, theatre and the company of other people. She was blessed with a close family who would visit her regularly and bring her back home when there were family gatherings.

The Coroner accepted that Rachel’s extensive dental surgery was necessary. At an earlier stage in proceedings it was not clear whether Rachel’s family accepted it was a reasonable cause of action, but there is no issue now taken with it by the family, or any other party to these proceedings.

There was a factual issue the Coroner had to rule on.

The care worker from Pirton Grange, Sheila Taylor, in her evidence on Day 1 said she was provided with a letter for Rachel’s GP and a generic information leaflet.

Staff Nurse Kate Griffith gave evidence that she had also provided an A4 or A5 leaflet about dental surgery with specific advice on bleeding.

‘Pirton Grange say they do not have a copy of that leaflet in Rachel’s file and interestingly the Acute Hospital Trust have no record of which leaflet was supplied. This court has never been provided with a copy of the leaflet’.

The Coroner described Staff Nurse Kate Griffith’s precise words as ‘helpful’. When talking about the GP letter and general leaflet she said that Sheila Taylor ‘was given’ them, but when referring to the dental leaflet she said she ‘would have been given an A4 or A5 leaflet’. The Coroner interpreted that as her usual practice, not a specific recollection.

On the balance of probabilities I am satisfied that no paperwork beyond the two items Sheila Taylor described, was provided to Pirton Grange.

Mr Twohig for the Trust earlier today accepted some criticism and said that it would be preferable if their information leaflet was refined for patients with a learning disability.

The Coroner was satisfied that Rachel was fit to be discharged on the Friday evening and that it was reasonable that she was.  

The Coroner went on to describe the care provided to Rachel once she returned to Pirton Grange, you can read more details on Day 1 evidence, Day 2, Day 3 and Day 4 here.

He described unchallenged evidence that Rachel’s breathing was rattling or chesty on the Friday night and that she continued to bleed.

By 10:30am on Saturday Rachel was described as gurgling, with watery blood coming out of her mouth.

By the time Gill Bennett called the NHS 111 service just before 19:15 on the Saturday she said she did think Rachel was at serious risk of injury and she accepted she should have called 999 or 111 or the hospital on Saturday morning.

Nurse Gill Bennett said that she usually did physiological observations but was unable to explain why, if she did those, she didn’t write them down.

In my view it would have been important to know what Rachel’s temperature, oxygen saturations and respiratory rate were, as she was already deemed at risk of aspiration.   

The Coroner then described the first call made to 111 and the response of the call handler. They should have called back in 30mins but didn’t, however the Coroner accepted:

I accept on the basis of the information provided to him or her [the 111 call handler] and the fact that the person making the call into the service was herself a health care professional, there was no reason at that time for the call to be escalated so it was dealt with earlier.

When the Out of Hours Nurse Alison Truman called the home back Gill Bennett had gone off shift, and Nurse Sheeba George spoke with her. She failed to provide any physiological observations or mention that Rachel had been chesty and gurgling earlier in the day. Alison Truman failed to ask for physiological observations, she said she’d assumed that they’d been done and the Pirton Grange nurse would have told her if there was anything unusual.

Alison Truman was not prepared to accept the criticism of the internal investigation conducted by her employers, Practice Plus, then CareUK, that she had failed to appropriately exclude a number of red flags and there was insufficient direct questioning.

It is of course easy to review this phone call with the benefit of hindsight. In my view Ms Truman is entitled up to a point to rely on what another health care professional was telling her.

However, physiological observations are basic medical checks and the information provided, could in my view, be extremely important.

I therefore do not accept it was reasonable for Alison Truman to assume Sheeba George had done those observations and that there was nothing of concern to report.

The Coroner accepted the court expert’s evidence about this conversation and found:

On the balance of probabilities she should have asked direct questions about Rachel’s bleeding, what her chest sounded like, and what most her recent physiological observations had been. These were questions a trained health care professional should have asked.

The PracticePlus/CareUK internal investigation also criticised Nurse Truman’s insufficient safety netting advice, which she accepted, and in the Coroner’s view had no bearing on the outcome in this case.

The Coroner went on to discuss Sheeba George’s evidence about making observations and recording them on a piece of paper which she failed to retain, or transfer to Rachel’s records, or relay to Alison Truman.

That evidence about a piece of paper came as something of a surprise. Ms George had mentioned nothing about it in her statement prepared for the inquest and said she’d only remembered about the piece of paper on Tuesday when she gave evidence.

On this part of her evidence I did not find Sheeba George to be a reliable witness…. it did not have a ring of truth about it, was only now 2.5yrs later that she remembered.

As a matter of fact, on the balance of probabilities, I find Ms George did not take any physiological observations that evening, and that’s the reason she did not mention them to Alison Truman in that phone call.

Furthermore, I find she did not even check Rachel’s notes for any further observations. Had she done so she’d have found the observations of Gill Bennett, and she would have been concerned enough from the blood pressure reading to relay that to Ms Truman.

The Coroner summarised the evidence relating to Rachel’s gradual decline, culminating in an emergency call and the arrival of paramedics shortly after 2pm on the Sunday. The paramedics relayed Rachel to hospital, where it was later ascertained she’d suffered an unsurvivable brain injury, as a result of her brain being starved of oxygen. She received intensive care treatment before the decision was made to move her to end of life palliative care, when she was returned to her home at Pirton Grange, where she died on the 13 November 2018.

The Coroner discussed the evidence of the ICU Consultant Dr Haynes, and the court’s expert witness ICU Consultant Dr Danbury about the onset of the hypoxia. He found:

On the balance of probabilities, by Sunday Rachel had already suffered some brain injury. She should have been admitted to hospital on Saturday evening, and if she had been she probably would have survived.

Returning to the question of the observations and care provided by the nurses at Pirton Grange, the Coroner again did not find Sheeba George a convincing witness. He felt on the balance of probabilities she did not do any observations beyond Rachel’s temperature overnight on Saturday. He found Gill Bennett’s evidence baffling.

Both those nurses accepted their training required they should have carried out regular observations, and documented them.

The Coroner found the contradictions in Sheeba George’s evidence:

…hard to reconcile, on one hand she accepts she should have carried them out and written them down, on the other hand she says they were told only to write down if they had concerns.

As a trained nurse… I do not accept that Sheeba George thought it was alright not to record those observations because the care home told her it wasn’t required.

No doubt if Pirton Grange had in place a more robust system with policies, procedures, training and auditing, both those nurses would have carried out regular observations on Rachel over those two days, but that does not excuse their own failings.

Basic nursing checks should have carried out and recorded, their failure to do so meant anyone, including themselves trying to build a picture of how Rachel was faring in the hours after her surgery were being denied key pieces of information.

The Coroner found on the balance of probabilities that it should have been obvious to staff at Pirton Grange from the saturation levels that Rachel’s condition was a cause for concern and help should have been sought.

The Coroner found that the failure of the two nurses to carry out and document observations, and the failure to seek emergency assistance from Saturday evening, amounted to a failure to provide basic medical attention to a person in a dependent position unable to provide it to herself.

He found each of those two incidents so total and complete, so patently not a simple error, that they could only be described as a gross error.

He found that the failures of the Out of Hours Nurse were things that any trained healthcare professional should have done. The Coroner commented that having listened to the transcript she was clearly attempting to do what was best for Rachel in difficult circumstances (giving phone advice on a busy evening, reliant on the information provided by those she spoke to, and without having the benefit of observing Rachel). Consequently he found that the fact she did not ask sufficient questions was a failure ‘perhaps even a serious one, but not so serious as to amount to a gross failure’.

To conclude the Coroner moved to whether the gross failures of the nursing staff at Pirton Grange had caused, or contributed to Rachel’s death. He explained he had to be satisfied that any gross failures had more than minimally, negligibly or trivially contributed to Rachel’s death.

Dr Danbury’s evidence was clear that Rachel should have been admitted on Saturday evening, and if she had been so admitted she probably would have survived.

I’ve already found the nursing staff should have sought emergency help from Saturday onwards. Had they done so I am quite satisfied on the balance of probabilities that would have warranted Rachel’s admission to hospital.

I’m satisfied if regular observations had been recorded, by Saturday evening they would have indicated the need for emergency assistance.

There is no evidence to the contrary.

Therefore I am satisfied on the balance of probability if Rachel had been admitted that evening, she probably would have survived and would not have died when she did.

Therefore the two failures did contribute to Rachels’ death.

The Coroner moved to sharing the particulars that would be entered onto the record of inquest in this case.

Cause of death

1a Cerebral hypoxia

1b aspiration pneumonia

1c dental extraction

2 hydrocephalus and epilepsy following childhood meningitis

On 26 October 2018 Rachel Johnston, who had significant physical and learning disabilities, underwent necessary and extensive dental surgery under general anaesthetic. Having been discharged that evening to Pirton Grange Nursing Home, where she lived, she developed aspiration pneumonia which resulted in her re-admission to hospital with an unsurvivable hypoxic brain injury

Rachel died on 13 November 2018.

Nursing staff a Pirton Grange failed to carry out adequate physiological observations on Rachel after her discharge from dental surgery, and failed to seek emergency assistance

Had emergency assistance been sought she probably would have survived and not died when she did.

Short form narrative:

Rachel died as a result of complications of necessary surgery, to which neglect contributed.

The Coroner concluded this hearing by addressing Mrs Johnston as follows:

Mrs Johnston if I can address you directly, can I start by offering you and the rest of your family my sincere condolences for your loss. The description you’ve given of your daughter, one can only attempt to imagine the hole left in your life as a result.

Also please accept my apologies on behalf of my for the fact although Rachel died back in October 2018, it is now 2.5yrs later we’re holding this inquest. There have been various delays and I hope you were kept abreast of them, but that doesn’t make it any easier for you and the rest of your family, please accept my apologies for those.

Inquest is adjourned. Will resume on 23 February 2021 to hear the remainder of the Registered Manager of Pirton Grange’s evidence and to discuss Prevention of Future Deaths reports.