Sally Lewis Inquest: Coroner’s conclusion

You can read the coroner’s summing up in three posts: Conclusion 1, Conclusion 2 and Conclusion 3. In this post I report on the coroner’s conclusion. This is what he said.

I’ve considered Professor Gilmore’s evidence carefully, I now incorporate into these findings the evidence of Professor Gilmore which I accepted.

I make these findings on the balance of probability:

1) Since September 2016 Sally was prescribed appropriate medication for her longstanding issue with constipation

2) Despite that, as per the MAR charts, Sally was not given any dose of Laxido after December 2016

3) That was because there was no proper or adequate regime in place to monitor and record Sally’s bowel movements

4) None of the Support Workers looking after Sally regularly had any proper or appropriate training on the important issue of constipation and bowel issues

5) Had they had such training they ought to have, and I find probably would have, known how important it was to monitor Sally’s bowel movements

6) Because the words ‘as required’ in the Laxido prescription on the MAR charts, should have used judgement on the issue. In order to do that staff needed to monitor Sally’s bowel movements as best they could. A regime ought to have been in place to monitor Sally’s bowel movements

7) If monitoring Sally’s bowel movements was proving difficult to do, Sally’s Support Workers could, and in my view probably should, have raised the issue with the Locality Manager Julie McGirr, with the Operations Director Julie Campbell, and of course with Dr Williamson, the GP himself

8) Had a proper regime been in place to monitor and record Sally’s bowel movements, it is likely in my view either sufficient Laxido would have been provided in addition to other medication to relieve Sally’s constipation, or, further advice would have been sought from Sally’s GP

9) Either way, if a proper regime was in place to monitor and record Sally’s bowel movements, Sally probably wouldn’t have died when she did

10) When Sally became unwell on 26 October 2017, those caring for her could not have been expected to recognise the onset of sepsis, or becoming seriously unwell, as opposed to the onset of the gastroenteritis virus affecting other residents and staff at The Dock.

The coroner said that he also had to consider neglect, and he reminded himself the test for neglect, to add a rider of neglect to any conclusion, he must be satisfied on the balance of probabilities that:

Firstly, failures taken together amount to failure to provide basic medical attention to Sally

Secondly, so serious can only be described as a gross failure

Thirdly, Sally is in a dependent position and unable to seek medical attention for herself, and

Fourthly, her mental state was such that staff ought to know … and [missed it, sorry]

Lastly, the coroner needs to be satisfied there is a direct causal connection, in other words, if this failure had not occurred, and an opportunity to provide care was taken, that Sally wouldn’t have died when she did.

The coroner then said:

I am grateful to Mr Hassall KC for his submissions on this, however, I must respectfully disagree.

[He explained why but I didn’t catch it all because my screen had gone a bit blurry, but I believe he was disagreeing with a submission made by Dimensions that because Sally’s constipation was a chronic condition over some years, that she was on other medication that could contribute to constipation, and that because a failure to monitor had been over a prolonged period, long before her death, that it was in fact not a failure].

Nor do I accept his contention any failure to monitor cannot be part of neglect … because it continued for 2 years before Sally’s death.

Having reviewed the findings of fact I’ve made I’m quite satisfied on the balance of probabilities that:

Firstly, the failure of those caring for Sally to appreciate regular monitoring of bowel movements was required in order to decide whether to provide Laxido, and failure to provide Laxido after December 2016, or to go back to the GP, did indeed amount to failure to provide basic medical attention … I do not include the failure on 26 October … in my view could not been expected to appreciate urgent medical attention for Sally was required.

Secondly, I am satisfied on the balance of probabilities, the cumulative failure was so complete, and so serious, it can only be properly described as a gross failure.

Thirdly, I am satisfied Sally was in a dependent position, unable to provide for herself.

Fourthly, Sally’s mental state was such staff caring for her knew, or ought to have known … [missed it]

Fifthly, given Professor Gilmore’s opinion, which I accept, had this failure not occurred … then I find on the balance of probabilities Sally would probably not have developed the gross faecal impaction that she did, and therefore probably would not have died when she did.

Therefore, I will include a rider of neglect.

The coroner then went through the record of inquest form.

In Section 3, when, where and how did Sally come by her death, the coroner said:

On the morning of 27 October 2017 Sally Lewis required 24 hour care, due to her significant learning disabilities, and who’d been unwell since the previous evening was found collapsed on the sofa at the Supported Living facility in Bromsgrove where she resided … an ambulance was called … she was declared deceased a short time later.

The coroner said that no short form conclusion could properly describe or summarise the events in this case, so he would give a short narrative conclusion.

Sally died as a result of faecal impaction, caused by chronic constipation. 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.

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 to administer the medication.

Sally’s death was contributed to by neglect.

The coroner concluded the inquest by saying he’d heard lots about what has changed and been put in place by Dimensions since Sally’s death, at all of their properties, and with the help of Worcestershire County Council.

If Sally’s death has achieved anything, it seems to me the changes hoped for her by her family seem now to be in place.

To their credit Dimensions seem to have understood the need to share… with others in the industry, for all those reasons it seems to me it won’t be necessary for me to provide a Prevention of Future Deaths report in this case. That brings an end to the formal part of this inquest.

The coroner offered Julie Bennett, on behalf of all of Sally’s family, his most sincere condolences, for their loss first of all, and extended his sympathies and apologies that we’re now holding this inquest 6 years after Sally’s death.

He explained that he would enter the details of his conclusion onto the computer system so that Julie didn’t have to make an appointment to enable Sally’s death to be finally registered. He said he’d write to her to explain more.

He thanked the family for all of their assistance in this long inquiry, thanked the barristers and solicitors who have assisted the inquest, and all the witnesses who had given evidence.

[I will at some stage report the remaining witnesses who we heard from today – Julie Bennett, Sally’s sister, Helen Orford from Discovery/Dimensions, and Susan Wall from the CQC].

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