The case of a 56-year-old man with Down’s Syndrome, who passed away in hospital after not receiving food for nine days, has led to significant controversy in the UK.
The man was being treated at Poole Hospital in Dorset, after being admitted with a hip fracture following a fall on his first night at a Bournemouth care home.
The case, which has been widely reported in media outlets including the BBC, saw the man die of pneumonia after a “series of errors” were made by the NHS hospital.
On admittance to the hospital, he was brought to the trauma and orthopaedics ward – where he was recorded as being “nil by mouth,” due to the fact he experienced trouble swallowing.
The man, who died in 2021, also had dementia, and was put into the care of a carehome after being looked after by his parents for the majority of his life. The hospital has been accused of “shocking mismanagement” of the unnamed patient’s nutrition, causing him to severely deteriorate, and eventually resulting in his death, according to the family’s solicitor, Adrian McCormack.
Poole Hospital further failed to adequately monitor and investigate the man’s condition, and also failed to provide senior doctors, according to Mr McCormack.
Junior doctors were also left unsupervised, not having access to senior staff or any route to escalate their concerns, allegations also said. No action was taken when the man was still nil by mouth after nine days at the hospital, despite the fact he was suffering from pneumonia.
The man’s family has now been awarded £15,000 in compensation, and has offered an apology for the failings.
The family, including the man’s father, also alleged that the hospital failed to provide adequate training to hospital admissions teams to make sure that patients with a disability or educational needs were getting the right treatment and care. The family said that speech and language therapists and dieticians were not contacted by the hospital to escalate concerns regarding the patient.
There was a failure in communication, a failure to advise consultants of the man’s deterioration, a failure to respond to the attempts of nurses to escalate the patient’s care, and a failure to provide any plan for the man, given his disability, and the worsening of his condition.
After the man’s death, an investigation was undertaken into his care by a consultant geriatrician, and a report was finalised five months after his passing. Six months later, the National Health Service’s (NHS) Litigation Authority admitted it had failed to provide the man with adequate care.
In a statement, it said: “On balance of probability, the admitted breach of duty caused a deterioration in the patient’s condition and he would not have died when he did.”
It said that the NHS trust had “learned from this very sad incident,” and had enacted changes to ensure a similar case would not unfold.
Chief executive officer at University Hospitals Dorset, Siobhan Harrington, chief said: “We offer our sincere condolences once again to the family and have apologised for the failings that resulted in his death.
“At the time, we undertook a serious incident investigation to identify any learning points.
“We have implemented a number of changes following this and have shared these with the family.”
The hospital paid £15,000 in compensation, while the care home involved paid out £7,500 to the bereaved family.
Mr Cormack, representing the family, said: “This was a shocking case. It was mismanagement by the hospital.
“Sadly, the damages for statutory bereavement are limited by law to just £15,120. This is wholly inadequate for bereaved families who have lost loved ones.”
National organisation Down’s Syndrome Association said it was “appalled” and “distressed” to learn of the recent case of failings involving the man.
“Acute hospitals should have specially trained learning disability liaison nurses to provide additional advice and support to the team caring for a patient who has a learning disability and, of course, all staff should be skilled in meeting the needs of any patient who has a learning disability and additional vulnerabilities, such as dementia,” the British charity representing those with Down Syndrome said.
“We very much hope that the hospital team will learn from this tragic case and ensure that systems are put in place to ensure that these failings could never be repeated.
“We are currently offering free training to Integrated Care Boards across the country focused on the health profile of individuals who have Down’s syndrome and an additional training session focused specifically on Down’s syndrome, ageing and dementia.
“We extend our sincere condolences to the family at this very difficult and sad time.”