Conclusion 1 reported the coroner’s summing up of events up until the day before Sally died.

Conclusion 2 reported the coroner’s summing up of the events surrounding Sally’s death, post mortem evidence and cause of death.

This post will discuss the coroner’s summing up in relation to what happened after Sally’s death including an internal investigation by Dimensions UK, a Worcestershire County Council Safeguarding Enquiry, evidence from Sally’s sister and from the court appointed expert Professor Sir Ian Gilmore.

The coroner said that following Sally’s death Dimensions UK conducted their own internal investigation carried out by Deborah Hubbocks.

In her investigation after reviewing all Sally’s documentation, and speaking to staff members at The Dock, Ms Hubbocks identified:

1) All staff at The Dock knew Sally had a long history of constipation and they also all knew about her medication for this.

2) There were no clear instructions about when to give Sally Laxido as and when required, but there were instructions from the GP in the MAR charts

3) There was communication about Sally’s constipation, for example, in handovers, but this wasn’t recorded in writing

4) She could find no documentation to suggest sally had been given Laxido since December 2016

5) In terms of medication audits, it appeared support staff had not been shown how to complete such audits

6) She was told by support staff, Sue Casey and by Julie McGirr, that they weren’t monitoring Sally’s bowel movements because she was independent in her toileting and they couldn’t tell when she’d been.

In terms of learning from her investigation, Ms Hubbocks said she thought more learning was needed about giving PRN medication, monitoring of bowel movements and measures to take when Sally had been to the toilet. Staff required more learning about recognising symptoms of constipation, staff didn’t fully understand what to look out for. She identified some medication Sally was prescribed that could have an adverse affect.

In addition to Dimensions’s internal investigation, Worcestershire County Council conducted a Safeguarding Enquiry after concerns were raised by Julie Bennett. It found:

1) Medication Support Plan was not detailed, although Laxido was noted on that, PRN as required, couldn’t find a PRN Protocol or Plan that outlined prescription details and what steps staff had to take to determine whether to use, and what to do if didn’t achieve the intended outcome, such as escalating to the GP.

2) Continence Plan made no mention of Sally’s constipation or how to be managed. It said expected bowel movements to be included in that plan.

3) Mobility Support Plan detailed Sally’s mobility could deteriorate when unwell. It noted Sally was unsteady on her feet the night before she died, questioned whether could been acted upon more early by staff.

4) Health Support Plan made no mention of constipation or how to monitor and manage it.

5) Health Action Plan was a plan introduced by the government to promote the overall health and wellbeing of people with a learning disability. Noted in the plan that Sally suffered constipation and Laxido was prescribed PRN, but that plan didn’t correlate with the Continence or Health Support Plans, neither of those mentioned constipation.

6) She said I noted electronic bowel movement charts were filled in sporadically, in September 2017 there was no recording at all … would expect more recording. It concerned me lots of recording of ‘no bowel movements’ and when large bowel movement Type 1 was recorded, no action was taken about this. Overall really concerned there was not much recording of bowel movements given Sally’s history and prescribed Laxido.

“I identified, and I note as others had, Sally was not given Laxido after December 2016” Julie Harris continued “I was concerned staff did not have sufficient knowledge about bowel issues and constipation, and insufficient oversight by managers”.

The Coroner said that then Worcestershire County Council involved their Quality Assurance and Commissioning Team, who worked with Dimensions to improve the situation and reduce risk to others.

Worcestershire County Council brought in training to supplement what Dimensions were doing, and for a period of time new referrals to The Dock were suspended, the coroner said. He continued:

I believe, she says, County Council does still commission services at The Dock and with Dimensions generally.

I feel, she said, the issues I identified at The Dock constitute basic safeguarding breeches.

The coroner also recalled the statement of Sally’s sister Julie Bennett, and the marked change in Sally’s behaviour, a month before her death … long way from the happy bubbly Sally I knew … and her stomach was getting bigger, although kept mentioning it to carers, they said they were monitoring her weight.

Lastly, the coroner said, we heard evidence from the expert witness Professor Sir Ian Gilmore.

He told the inquest Sally’s medication regime at the date of her death was firstly Senokot liquid twice weekly, a stimulant laxative aimed at helping the bowel move things along. Secondly Bisacodyl once daily, another stimulant laxative, and thirdly PRN Laxido, as required, a different type of laxative, an osmotic, that draws fluid into the bowel to make stool softer.

This had been the regime from September 2016 at least, he understood Sally was on a number of other medications … think more likely than not anti-psychotic medication was a significantly contributory factor to Sally’s constipation, and we also know people with a learning disability are more prone to constipation, the coroner said.

Both these factors are fairly widely known … Prof Gilmore said he’d certainly think psychiatrists would be aware, couldn’t say whether that would be known by GPs and those working in care settings.

So far as Sally’s medication regime was concerned, I do think this was an appropriate medication regime, reasonable to add Laxido PRN as Sally’s needs could vary.

When asked was the regime being followed he said he couldn’t find that out. He was unable to find regular reference to bowel function … noted Laxido was not given at all after December 2016.

How should Sally’s constipation be managed? Professor Gilmore said a stool chart should have been used to record consistency and frequency of stools passed, only then could it be judged whether to use the Laxido PRN.

There were some records, but not daily, and not of sufficient quality to assist with that decision.

I didn’t gain the impression those caring for Sally had a consistent idea of what they were recording.

The coroner said Prof Gilmore said he could appreciate that scrutinising visits to the toilet can be difficult, so there may be a need for a degree of compromise. The coroner then listed the symptoms of constipation as shared by Professor Gilmore.

So far as the 22 entries on the electronic chart at p2657 he said these entries are insufficient, too irregular to allow those caring for Sally to make an informed decision about whether or not to give her PRN Laxido.

The coroner said that Prof Gilmore said it was not possible to tell how long Sally had been suffering severe constipation leading up to her death, but he referenced the behaviour changes noted by her family and distended stomach. He said that it “Certainly can take weeks, and probably months to build up”.

On balance of probabilities someone with that degree of colonic distension, you would expect to see some evidence of pain and discomfort, but if Sally was in that state for some time she may have become attuned to it to some degree.

The coroner said that Prof Gilmore had commented that the symptoms Sally experienced on the 26 October 2017 were likely related to the lining of her bowel becoming necrotic, allowing toxins to enter her bloodstream, which then led to sepsis, and then to death.

Distension was what was compromising the lining of the bowel, leading it to become necrotic.

On the balance of probabilities if Laxido had been given when required Sally would not have died when she did.

He said that if the Laxido hadn’t worked it should have been escalated to the GP. Professor Gilmore was of the view that if Sally had not died when she did, her bowel would have perforated leading to peritonitis, a serious condition that would likely require surgery.

As a hospital specialist he said it “would amount to basic medical care”, but it was not for him to say in this care setting whether that would be the case.

In answer to questions from Stephen Clarke, Professor Gilmore said it was a very unusual cause of death, but the symptoms the evening before were likely consistent with septicaemia, although death in 12 hours was probably faster than average.

Answering a question from Mr Hassall KC, of whether clear instruction needed to be given dependent on experience of care staff, Professor Gilmore said that the instructions given for one as required to get one daily motion, he said:

Appears to me a fairly easy instruction to follow.

He was referred to a hand written note on Sally’s records dated 5 January 2017 saying Senna not given that day due to loose [stools].

It would be speculative, Professor Gilmore said, whether if Sally had loose stools due to Laxido given 8 days earlier, could be equally due to faecal overflow … when fluid produced … that flows past the stool and may look like diarrhoea.

I agree he said monitoring of bowel movements is vital. Bowel movement charts should record date, size, consistency and Bristol Stool Chart category.

Looking at all the evidence he said is a possibility Sally passed stools unsupervised, but equally possible she didn’t pass any stools.

He’d have expected a minimum standard, noting consistency and frequency of stools passed.

He agreed it was different to do for a patient like Sally to a patient with full capacity. He would rely on carers informing him if it wasn’t possible to monitor her bowels sufficiently.

I don’t think Sally’s carers on ground should be coordinating her bowel care, but I do think they should have been completing bowel charts, he said.

[The next post will discuss the coroner’s final conclusion, after his summing up].