Sally Lewis’s inquest concluded this afternoon with the coroner finding that her death was contributed to by neglect.

David Reid, Senior Coroner for Worcestershire said that no short form conclusion could properly describe or summarise the events in this case, so he’d give a short narrative conclusion. I’m going to report this in stages, this first post covering events up until the day before Sally died.

The coroner found Sally died as a result of faecal impaction, caused by chronic constipation. He found that for the ten months prior to her death the medication prescribed to treat her constipation on an as required basis had not been given to her. He said this was because there was no regime in place to record and monitor Sally’s bowel movements in order for the staff looking after her to judge whether they needed to administer the medication. He found that Sally’s death was contributed to by neglect.

Before giving his summing up and conclusion the coroner repeated his warning to those attending remotely about contempt of court. He then summed up what had been heard in court [I can type quickly if I say so myself, but even I couldn’t catch it all]. This is what I recorded from his summing up.

Sally Lewis was born on the 25 June 1962 and she was therefore 55 years of age at time of her death on 27 October 2017. Sally lived with a number of conditions, including a severe learning disability, although she was able to communicate some basic needs through single words, she was largely non verbal.

She had for many years been diagnosed with schizophrenia… she was on medication… she had many challenging behaviours. She had also undergone major surgery 10 years prior to her death, after being diagnosed with Ovarian Cancer.

The coroner said, most pertinent to this inquest, was the fact that Sally was prone to constipation, which she had been seen by her GP about on many occasions. Sally was wholly dependent on the care of others for her day to day living.

Mr Reid said, nevertheless, it was quite apparent what a larger than life character Sally was, how much she got out of life and how very much she was loved by her family and friends.

Since May 2016 Sally had been living at The Dock, a Supported Living placement Bromsgrove provided by Dimensions UK. Sally’s placement was fully funded by Worcestershire County Council. Sally had previously lived in another Dimensions service at Stourbridge Road.

Sally was one of three residents at The Dock, all with different needs. Care was provided by a number of Support Workers, many of whom had known Sally since her time at Stourbridge Road. The coroner said that the Support Workers were overseen by the Locality Manager, Julie McGirr. He added that Sally had a Key Worker, Sue Casey.

There were no nursing staff employed at The Dock, so Sally was reliant on her care workers to meet her basic needs, including seeking support from other professionals when required. The coroner found that there was no constipation support plan in place.

In October 2015, two years before her death, Sally was seen by Dr Sarkar, one of the GPs at her local surgery. Dr Sarkar notes that although Sally was on a daily dose of the stimulant laxative Bisacodyl, carers had stopped giving her Laxido, a different type of laxative, an osmotic laxative, because her stools were loose.

In fact the GP, Dr Sarkar, identified this as likely constipation with faecal overflow. She advised the carers to re-start the Laxido at one daily and increase if there was no improvement.

In September 2016, Dr Williamson saw Sally, with one of her carers, for her annual Learning Disability Review. Dr Williamson told the inquest that he was told things were improving and Sally was a lot more settled. He was told there were no issues with her constipation and that she was receiving Laxido regularly, but not every day, and she was passing stools once a week.

Dr Williamson felt that Sally was still suffering from constipation because she was only passing one motion a week and experiencing discomfort when passing stools.

The coroner paused there and said that he found, as a matter of fact, that discussion must have taken place and been with the carer.

Dr Williamson started Sally on what he described as a a “cautious dose of Senna”, and told the staff member that if it didn’t result in one daily motion, of a good size, that they should return to the GP so the dosage could be reconsidered. The coroner said that Dr Williamson advised in that review that reference should be made to the Bristol Stool Chart. I would agree, he said, that Sally’s documentation must include lack of bowel movements, as well as recording the frequency and consistency of stools that she did pass.

Dr Williamson said he did advise the carer that agitation could be a sign of constipation, although he recognised Sally could be agitated for other reasons, which was why he advised carers to return to the GP if they were unsure. No concerns were raised with him about difficulty monitoring Sally’s bowel movements because of her need for privacy.

Dr Williamson described the advice given as a basic level of medical care. The coroner said that it seemed to him therefore, and he found on the balance of probabilities, that Sally’s medication consisted of daily Bisacodyl, Senna one dose twice a week and thirdly the Laxido.

The coroner said that information was contained in the MAR charts which were contained within Sally’s documentation at The Dock. These charts set out prescribed medications and their doses and staff had to record every time a dose of one of those medications was given to Sally.

The coroner found that the wording on the MAR charts in relation to Laxido read: one sachet daily when required to try and get at least one soft daily motion. Question was raised whether that was somewhat ambiguous, for example, once one daily motion was achieved, were staff to stop Laxido or continue on that dose?

“Key it seems to me”, said the coroner, “is the word ‘as required’, which indicated staff should use their judgement on the issue. In order to do that they needed to monitor Sally’s bowel movements as best they could”. The coroner added, “furthermore if there really was any confusion about that, the obvious thing to do would have been for the care staff to go back to the GP… of course this was never done”.

Surprisingly therefore, the coroner said, we could see from the MAR charts that since the September 2016 appointment with Dr Williamson, Sally was given the Laxido twice in September 2016, twice in December 2016 and never again thereafter.

The coroner found that charts seem to be filled in as should be, in all other respects, so he found as a matter of fact, as per those charts, that Sally was never given Laxido again after December 2016.

The coroner said that it seems common sense, in order to decide whether Sally needed Laxido, staff at The Dock would need to monitor her bowel movements.

All support workers at The Dock knew that Sally had issues with constipation. It was concerning to hear the manager at the time Julie McGirr say she did not know this.

Although once pointed out what was in Sally’s Health Action Plan she did concede she probably did know about that, because she would have read that document, said the coroner.

With the exception of one, all regular Support Workers said that they knew Sally was on medication for her constipation. All but one recalled that she was prescribed Laxido, as required.

Sally’s Key Worker Susan Casey said she did remember Sally had medication for constipation, as far as she was aware her constipation was fine. She said that she didn’t remember any discussion between staff about Sally’s constipation. Ms Casey said the MAR charts suggested that Sally should be taking Laxido, as required, which she took to mean if Sally appeared in pain, or was not eating properly.

What to my mind is really concerning is with the exception of one, Sally’s regular Support Workers made no mention of recording bowel charts to chart Sally’s bowel movements. Susan Casey said we didn’t have a bowel chart, when I asked how would you be able to go back to the GP and say the Laxido was working, Sally was passing one soft stool, she said we wouldn’t be able to.

When asked about one entry dated October 2017, Ms Casey said it was recorded by her “Type 1, hard and lumps” and the only reason she put that in the records was because it blocked the toilet up. “I didn’t think anything” she said about numerous other entries on that document that said Sally had no bowel movements.

Support worker Callan Glassey said “I was not told we should document resident’s bowel movements”. Another support worker, Anne Venn, said Sally usually had a bowel movement twice a week, anything unusual would be recorded in her daily notes.

Laura Rumble, at the time of Sally’s death had only worked at The Dock for two months, she said “when I spoke about this I was told none of the three residents at The Dock met higher criteria for bowel monitoring” … she didn’t question what the criteria was. She said that she was being trained so never completed bowel charts for Sally herself, some did, others didn’t. She said that when she raised it with Sonia Parchment she said it was “a matter of what I felt comfortable with”.

The exception to this, the coroner said, was support worker Victoria Howe. She said it was common practice to record any bowel movement’s residents had, that she’d always done that. She said she would record in the back of Sally’s daily notes, if she didn’t have a bowel movement she wouldn’t record that in the daily notes. I did know, she said, if Sally hadn’t had a bowel movement for 3 days she should have PRN medication and she would check by referring to MAR sheets.

The coroner said that she was taken to one of the sheets at the back of the notes, she said this was the page where she’d record bowel movements, and they’d all been given training on how to complete these documents.

The coroner paused there to say that the sheet she was referring to was not in fact a bowel chart. It was a chart on which support workers were required to indicate if a bowel chart was in place, and if so where that document could be found.

The coroner said that Ms Howe was taken to the summary of the electronic bowel records and she agreed she had made entries on that. She said:

“I did record 10 August 2017 that Sally seemed constipated. She’d pace around a lot, her stomach seemed quite hard, she’d sit on the toilet for some time without much comment”

Ms Howe said that her entry that recorded Sally’s bowel movement as being Type 1 hard lumps, as far as she was concerned that was normal for Sally and she wouldn’t have given her Laxido if she passed a stool like that.

When taken to the charts at the back of the daily notes between June 2016 and June 2017, she said “I’m not surprised there were no entries by me, I didn’t witness many of Sally’s bowel movements”.

When Victoria Howe was asked the question if she had to know whether to give Laxido, how would she know whether Sally had a bowel movement for the last 3 days, she said… “if it was not recorded or handed over they’d had a bowel movement, can assume that they hadn’t had a bowel movement”. The coroner said that this evidence about whether and when to record was indicative of a “complete lack of planning” when it came to Sally’s constipation.

The Coroner said that it was quite clear Dr Williamson’s prescription required staff at The Dock to use their judgement, about whether to use it [Laxido] and in order to do that, they needed to record.

Quite clear to me, I find as a matter of fact, none of the Support Workers looking after Sally regularly had had any proper or adequate training on the important issue of constipation and bowel movements.

He added that if they had, it seemed to him, they would have realised that Sally’s bowel movements needed recording and monitoring.

Nevertheless many Support Workers were still very experienced, quite capable of recognising Dr Williamson’s prescription needed them to exercise judgement, if unsure of how to proceed they ought to have raised it with their Manager, Julie McGirr.

The coroner said that as Locality Manager for The Dock, Ms McGirr was responsible for ensuring her staff understood the importance of monitoring and recording.

It’s quite clear to me Julie McGirr put no system in place to ensure her staff knew what to do about Sally’s bowel issues, furthermore although expectation records monitored every month, was quite clear that wasn’t happening.

The Coroner said that June 2017 was the final month where paper notes were used at The Dock, and between June 2016 and June 2017 none of those documents indicated a bowel chart was being used. Yet this was not picked up in the monthly audits.

The reason for this was given in stark terms by Julie McGirr in her evidence, she said I’m not surprised none of those audit sheets were completed during that period, she said she didn’t have time to do that task.

The coroner said Julie McGirr said she was regularly working above her contracted hours and she believed her line managers were aware of the stresses she was under.

Julie McGirr also agreed MAR charts should be audited monthly, because she didn’t audit these either, she didn’t pick up on the fact Laxido was prescribed regularly, but simply not being used.

The coroner said he had also heard evidence of Julie Campbell, Dimensions’ Operation Director.

She agreed at the time Dimensions did not have any training in place for staff about constipation.

The coroner said she accepted that there were internal Dimensions quality assurance processes in place, yet no review for Sally, or any other resident at The Dock, revealed any concerns about record keeping.

Julie Campbell was honest enough to concede in her evidence that given the lack of record keeping here, she was surprised the Quality Review concluded was no issues with record keeping.

She said she would expect them to pick up the lack of entries on electronic bowel charts and a conversation with Julie McGirr should have ensued.

The coroner said that the court had the electronic bowel charts from 1 January 2017 to the date of Sally’s death on 27 October 2017, and that in that entire 10 month period, only 22 entries were made.

When asked about the lack of any Laxido being given to Sally after December 2016, Julie Campbell said she’d have expected Quality Review to pick up on it and discussions to take place. She said she was never informed Quality Review had picked up on it and she said I think therefore we can conclude the issue was not picked up on.

Pausing there, common thread in evidence of The Dock support workers was in any event it could be challenging to monitor Sally’s bowel movements, Sally they said was very independently minded, and able to go to the toilet herself, and often took exception to her visits to the toilet being scrutinised.

That it seems to me is simply no excuse for not attempting to monitor her bowel movements.

The coroner said that Julie Campbell told the inquest she was aware difficulties in monitoring Sally’s bowels, recalled input from behaviour specialist before Sally was at The Dock, at no time when Sally was at The Dock did anyone raise with her that they were meant to be monitoring Sally’s bowel movements, and it was difficult to achieve. She said it would be up to Support Workers and the Locality Manager to monitor, if not go back to the GP, or contact Julie Campbell or speak to the Learning Disability Advisor.

It seems to me that is right. Dr Williamson’s instructions were clear and ought to trigger monitoring … if that proved difficult in any way … the problem could, and I find should, have been raised with Julie McGirr, Julie Campbell and Dr Williamson, the GP himself.

[The coroner then moved on to discuss the events immediately preceding Sally’s death, I’ll report them in a separate post Conclusion 2 here].