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'Missed opportunity' to save man, 33.

A "missed opportunity" for potentially life-saving treatment contributed to the death of a man from complications caused by severe constipation, a coroner ruled after an 11-day inquest.

Down’s syndrome sufferer, Richard Handley, 33, died at Ipswich Hospital on 17 November 2012. He had been admitted three days earlier after his family became concerned about his distended abdomen, which made him look "full-term pregnant.

He had an operation that removed around 10kg (22lb) of faeces from his body on November 15.

A pathologist at Ipswich Hospital, Jason Wong, said that Richard Handley died as a result of choking on his own vomit after inhaling gastric contents following complications after the surgery.

The coroner, Dr Peter Dean, said that there had been missed opportunities to alert more senior staff to Richard Handley’s condition but recorded a narrative verdict.

Mr Handley was born with moderate learning disabilities and bowel problems. Family members said they provided daily laxatives and a high-fibre diet to alleviate his constipation.

He was moved to a care home in Lowestoft in 1999, This resulted in changes to his diet and a reduction in monitoring his bowel movements, leading to his constipation worsening.

After mental health and behavioural problems, Mr Handley was moved in 1999 to Bonds Meadow care home in Lowestoft, which was turned into a supported living complex in 2009.

Richard Handley’s mother, Sheila, told the inquest that when the care home was turned into a supported living complex in 2009, the family became concerned about his diet and a lack of monitoring of his bowel movements.

She said that when she raised the question of her son being allowed to eat whatever he wanted, she was told it was "because he had a right to.”

The coroner said this was the start of a chain of events and, without them, his "death would not have occurred.”

He added that several different agencies were looking after Mr Handley. There were "gross failures" in identifying that he was in a critical state after the surgery. An overall care co-ordinator "would have prevented this from happening.”

Tim Cooper, chief executive of United Response, which ran the home where Mr Handley lived, said the organisation "could, and should, have done better.”

He added: "The coroner concluded 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."

Chief executive of The Ipswich Hospital NHS Trust, Nick Hulme, said: "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."

Outside the court, Mr Handley's mother, Sheila, who gave evidence during the inquest, said she was "disappointed" with the coroner's verdict.

She said: "Hearing about the gross failures identified and missed opportunities, I find it very hard to understand how the coroner didn't feel able to use the word 'neglect' in his conclusion.

"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 he needed to keep him safe."

Suffolk County Council director for adult care, Mike Hennessey, said the authority had already taken significant steps to address the recommendations of the serious case review.

He said: "Alongside all organisations involved, we are fully committed to further work to improve the health and social care services provided to people with learning disabilities in Suffolk."

 

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