SERIOUS concerns have been raised at the care of a ‘vulnerable’ 83-year-old at the Harold Kidd Unit in Chichester.
However, despite concerns raised by Maureen Leaver’s family, the coroner said she did not lose an ‘opportunity to live’ by being placed on the Liverpool Care Pathway, when she was later admitted to St Richard’s Hospital, in Chichester.
Assistant coroner for West Sussex Karen Henderson said she would write to the Sussex Partnership NHS Foundation Trust with a prevention of future death report concerning treatment at the Harold Kidd mental health unit, in Blomfield Drive.
As reported last week, the inquest, which concluded on Monday (December 2) with a narrative verdict, heard Mrs Leaver was left for two days before medical staff realised she was suffering side effects from medication and hypothermia.
She later died at St Richard’s Hospital, in Chichester, on October 6, 2010.
Mrs Leaver was admitted to St Richard’s on September 26, 2010, with profound hypothermia after spending two months at the unit.
It was at Harold Kidd that Mrs Leaver was given the drug risperidone by staff who did not follow guidelines about its prescription.
Dr Henderson said Mrs Leaver had shown a ‘slow cognitive decline for a number of years’, but with the support of her family had lived independently until her admission to the mental health unit in July, 2010.
The inquest found Mrs Leaver received barely any supervision from a senior doctor during her stay on Grove Ward.
“There was a junior doctor on the ward but there was minimal consultant supervision. In one period no senior medical consultant saw Mrs Leaver for a period of 17 days,” said Dr Henderson. She added there were ‘long-running complaints’ by nursing staff about the temperature, with a policy that the heating was not put on until October 1.
She accepted evidence that the onset of hypothermia was likely to have started on September 24, two days before Mrs Leaver was admitted to St Richard’s.
“Whilst there is a need for efficient use of heat, no establishment should have to beg to have the heating put on and for it to be effectively under the control of one person,” she said, adding: “After Mrs Leaver was transferred to St Richard’s Hospital, the ward manager wrote an email on September 26 detailing how cold it was with inadequate numbers of blankets for the patients, staff wearing coats etc.”
In her summing up, Dr Henderson said the causes of death were bronchopneumonia, hypothermia, risperidone toxicity and sepsis. She also cited other factors including dementia and type II diabetes.
Concerning the decision by a consultant at St Richard’s to put Mrs Leaver on the pathway, Dr Henderson said more time should have been given before making the decision, but she believed the consultant knew Mrs Leaver was dying and wanted to do the best for her.
Sussex Partnership said it deeply regretted the care at Harold Kidd had fallen below its standards. Helen Greatorex, executive director of nursing and quality and Tim Ojo, executive medical director, said: “On behalf of the trust we offer our sincere and heartfelt apologies to Mrs Leaver’s family and to everyone else affected by these events.”
They said services had changed to provide better support and patients were now safe and cared for to the standards the trust expected.
Mrs Leaver’s family made no comment on the verdict.