‘Missed opportunities’ highlighted after death of Richard Handley
- Credit: SUPPLIED BY FAMILY
The mother of a vulnerable Suffolk man who died as a result of 'missed opportunities' has said she is 'not content that lessons have been learned'.
Richard Handley, who had Down's Syndrome, died at Ipswich Hospital in November 2012 as a result of complications from a bowel obstruction.
He was first admitted to the mental health unit before being transferred to A&E due to an enlarged abdomen. Scans revealed he had severe constipation and he under went surgery to remove 10kg of faecal matter, but died as a result of complications.
During his inquest, which concluded at Beacon House in Ipswich yesterday, Suffolk coroner Dr Peter Dean said there had been 'missed opportunities' to provide 'potentially life-saving intervention' and 'gross failures' from those caring for him.
The 33-year-old had life-long constipation problems and mental health issues.
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Evidence revealed that he was on a high fibre, low sugar diet, and that his bowel movements were carefully monitored by staff at Bond Meadows Care Home in Lowestoft – the United Response-run establishment where he lived.
The inquest heard that when Bond Meadows changed from a care home to a supported living establishment in 2010, Richard's diet and bowel monitoring slipped, with his family told that 'he had the same right as anyone else to make unwise choices and eat unhealthily'.
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It was found that GPs missed an opportunity to refer Richard to hospital when they carried out a home visit just days before his death, while elevated readings in A&E were not raised with senior doctors, which could have seen him treated quicker.
Recording a narrative conclusion, Dr Dean said he could not record 'neglect' because more than one factor had contributed to his death, but that Richard 'should still have survived'.
Richard's mum Sheila Handley said: 'I find it very hard to understand how the coroner didn't feel able to use the word neglect.
'It feels to me, having heard all the evidence, that the level of the failures was such that Richard died because he was neglected. He wasn't given the care that ne needed to keep him safe.
'I don't feel content that lessons have been learned. I have been hearing for the last five years that lessons have been learned, and yet the deaths continue.'
Ipswich Hospital statement
Nick Hulme, Ipswich hospital chief executive: 'I am extremely sorry that we let Richard and his family down in the last 48 hours of his life.
'I want to give my personal assurance that we have learned from this tragedy and improved the care and support we provide for people with learning disabilities and patients whose health is rapidly deteriorating.
'This is what I said at the time when the serious case review into Richard's care was published in 2015.
'I have met with the family to offer my apologies and condolences and I feel it is very important to say it again today, at the conclusion of the inquest.
'The trust carried out a number of investigations both internally and externally into Mr Handley's care and those investigations did raise areas of concern.
'As a result the trust put in place a detailed action plan to ensure that lessons have been learned across the trust and that any changes which needed to be made have been identified.
'The action plan has been implemented and a number of people have been involved in ensuring that appropriate action has been taken since this sad death over five years ago.'
United Response statement
Chief executive Tim Cooper said: 'We were deeply saddened and affected by Richard's tragic death in 2012. Our local staff cared greatly for Richard for 13 years and our thoughts continue to be with his family and loved ones.
'Providing the right care and support to someone with a learning disability and complex health needs, as Richard had, can be challenging and requires many organisations to communicate, work together and to each understand their role.
'We accept that in Richard's case this simply did not happen well enough.
'At United Response, we could and should have done better.
'The coroner has concluded today that everyone involved in his care acted in good faith to assist him at all times, but it's clear that we collectively failed Richard.
'We are incredibly sorry for Richard's death.
'Situations like his are rare but there are lessons for each organisation to learn from and act upon to provide truly integrated support for those with learning disabilities in the future.
'We have taken Richard's death very seriously and have since commissioned an independent inquiry, improved our staff training and revised our policies and practices for supporting people with similarly complex medical conditions.'