Grandmother died after assault by violent dementia patient

THE family of an 89-year-old grandmother who died after being assaulted by a violent dementia patient at Ipswich Hospital is considering campaigning for a law in her memory after highlighting concerns about the care she received.

Jay Moss, grandson of Caryl Ann Mclaren,  said he wanted non-dementia patients to be cared for on separate wards from dementia patients and would call for such a regulation to become law if necessary.

The inquest had heard Mrs Mclaren sustained multiple fractures and injuries a day before she was due to be discharged.

Mr Moss spoke following an inquest into her death at which Suffolk coroner, Dr Daniel Sharpstone, recorded a narrative verdict. 

Dr Sharpstone said that Mrs Mclaren, from Holland-on-Sea, died from injuries she sustained during the attack in the toilets by a dementia patient on Grundisburgh Ward on January 5, 2022.

The patient had been on an open hospital ward for three months because his care home could no longer care for him.

The inquest also heard she had received four or five times the guideline amount of painkilling drug oxycodone as medics treated her injuries, although Dr Sharpstone found this did not contribute to her death.

Instead, he said the multiple fractures she received during the assault had led to her death after a consultant deemed she was not fit to be operated on.

Mr Moss said: "I am happy the facts have now been produced, but I am going to continue to fight for improved care.”

He was joined at the inquest by Mrs Mclaren's daughter, Loraine Moss, and son-in-law Mick Moss who said: "We want to know that changes have been put in place so it can't happen with somebody else."

Mick Moss said that he was particularly concerned that Mrs Mclaren was placed on a ward with dementia patients, despite having no signs of dementia herself, while proper risk assessments had not been carried out on her assailant, referred to as Mr X during the inquest, including his mental health.

Mr Moss added: "If you have got a patient there with that sort of history, they should be monitored 24/7."

Earlier in the inquest lead anaesthetist consultant at Ipswich Hospital, Dr Helen Findley, said she did not believe the oxycodone overdose had been a contributory factor because she would have expected to see high carbon dioxide levels in Mrs Mclaren's blood, but levels of the gas were low.

The inquest had previously heard how Mrs Mclaren had been admitted to the hospital on New Year's Day, 2022 with shortness of breath.

During the assault, nurses heard a 'loud bang' and Mrs Mclaren calling for help, while a man – Mr X -  was stood outside the toilet door.

She had pushed back as the patient tried to get in before losing her balance and falling on the floor. She died from her injuries, including fractures to the shoulder and femur, six days later.

It is understood the complex care team at the hospital had requested the ward carry out a mental health assessment on Mr X before the incident but this was completed only after Mrs Mclaren had been assaulted.

A patient safety investigation report found that, if had there been a formal risk assessment of aggressive behaviours, formal referral to a dementia specialist, increased level of staffing and a mental health referral, then the incident could have been prevented on the balance of probabilities.

While recording his verdict, Dr Sharpstone said: "Because of her frailty and number of fractures and because the consultant did not consider that she was fit for an operation, I think that, even without the oxycodone, she would have proceeded to end-of-life and I don't consider that the oxycodone contributed to her death."

However, he has asked for the hospital, run by East Suffolk and North Essex NHS Foundation Trust (ESNEFT), to provide evidence that the concerns raised in the inquest had been incorporated into teaching programmes and guidelines for the dissemination of medications.

Following the inquest, chief nurse at ESNEFT, Giles Thorpe, said: “Our own investigation has led to a wide range of changes being made throughout the trust to make sure that we learn from what happened.

“We have shared these changes with Mrs Mclaren’s family and are continuing to work with the coroner to provide assurance of the actions we have taken.”