Eliot Harris inquest raises care criticisms

The recent inquest into the death of a Norfolk man has concluded by recording an open verdict and making several criticisms regarding the care he received while at Northgate Hospital in Great Yarmouth.

During the two-week inquest held at Norfolk Coroner’s Court, Eliot’s family were represented by Fosters’ Carl Rix and Hannah Noyce of 1 Crown Office Row.

Eliot Harris from Cromer, with diagnoses of schizophrenia and type 2 diabetes, died unexpectedly aged 48 at Northgate Hospital, on the 10th April 2020.

The jury concluded that the cause of Eliot’s death remains unascertained but heard evidence concerning standards of care and the falsification of observation records at Northgate.

Speaking at the conclusion of the inquest, Sally Harris, Eliot’s mother commented: “I am disappointed that the inquest did not return a clear conclusion as to the cause of Eliot’s death, and feel that we have been left without many of the answers that we deserve.

“I did not receive a letter informing me of Eliot’s residence at Northgate until after his death, and no explanation was provided for this. I am pleased however that the jury made several serious criticisms of the care that Eliot received during his time at Northgate. I hope that lessons are learnt from these criticisms so that standards are improved, and no future patient is subject to the appalling level of care that Eliot received.”

Carl Rix of our Medical Negligence & Inquests team added: “It has been a privilege to represent Sally over the last two years. She has shown immense bravery and courage throughout what has been an incredibly difficult time. The evidence heard at the inquest certainly justified the concerns that Sally had about the care Eliot received. We sincerely hope appropriate measures will be put in place to prevent this from happening again.”

The inquest

Before HM Senior Coroner for Norfolk, Jacqueline Lake

Norfolk Coroner’s Court, County Hall, Martineau Lane, Norwich, NR1 2DH

25th July – 8th August 2022

The family was represented by INQUEST Lawyers Group member Carl Rix of Fosters Solicitors and Hannah Noyce of 1 Crown Office Row.

Norfolk and Suffolk NHS Foundation Trust, the CQC, and three former employees of the Trust were separate interested persons in this inquest.

Eliot had a long-term history of mental illness, which begun after he was attacked by a group at the age of 16. Following his first admission to Northgate Mental Health Hospital in 1993, Eliot moved between psychiatric hospitals and specialist homes, and never spent substantial time living independently in the community again. Eliot had been a resident at Elsenham House Nursing Home in Cromer since 2017. In early April 2020, Eliot’s mental health deteriorated. He became non-compliant with his anti-psychotic medication, and was verbally and physically abusive, which was out of character. Following a Mental Health Act assessment on 5th April 2020 in which he was found to be floridly psychotic, Eliot was admitted to Northgate Hospital under section 2 of the Mental Health Act. He was initially placed in seclusion, before being released onto the ward on 6th April 2020, under four observations an hour.

In the days leading up to his death, Eliot was largely bedroom-based. He struggled to communicate with staff, often attempting to express his needs via blinking. He continued to refuse oral medication. However, he did accept intramuscular injections, the last of these being a haloperidol depot injection administered on 9th April 2020.

The jury found that Eliot’s food and fluid intake was minimal throughout his time at Northgate. Staff at Elsenham House had previously managed Eliot’s diabetes’ diagnosis through careful monitoring of his diet. They were successful in this, to the extent that a blood test taken on 7th April 2020 showed that Eliot’s HBA1C levels were within normal limits. Despite Eliot’s history of diabetes being noted on the documents with which he was transferred to Northgate, Eliot was not entered onto a food and fluid chart on arrival or at any time during his admission. He did not eat a full meal in the four days that he spent at the hospital, and only ate cheese sandwiches. There was no formal process in place to monitor his diet or fluid intake.

In the record of inquest completed by the jury, it was further noted that an electrocardiogram was recommended and requested to be carried out, but had not been carried out by the time of Eliot’s death.

The inquest also investigated the adequacy of therapeutic observations carried out by Northgate staff on patients during the time of Eliot’s admission. The jury heard evidence that staff considered observations to be merely a headcount. Several staff received no formal assessment of their competency to carry out observations during their time on the ward. It was heard in evidence that if observations were not carried out during a shift, observation charts would be left in the pigeonhole of staff who had worked that shift, with an expectation that they be falsified retrospectively. During the inquest, the Norfolk and Suffolk NHS Foundation Trust made the following admission:

The Trust accepts the position that as at April 2020 there was a culture within Northgate hospital of retrospective recording of:  

(a)          Observations done but not contemporaneously recorded;  

(b)          Observations done by others but not recorded by them and signed by others on their behalf;  

(c)           Observations that were not completed by anybody but were falsely signed as completed;  

In respect of the retrospective recording, it is further acknowledged that the aforesaid was encouraged and expected by the ward managers and at times the recording would be done days later.

CCTV footage was cross-referenced with the observational logs completed by ward staff on the night that Eliot died. The inquest heard written evidence from a Senior Investigating Officer from the Norfolk Constabulary, who noted 23 occasions between the hours of 17:00 and 00:32 where staff had signed to have completed observations on Eliot that CCTV revealed they had not in fact completed. In the record of inquest, the jury criticised the falsification of observations over the night of 9^th and 10^th April 2020. Building on the Trust’s admission, the jury further noted: ‘observations were completed by staff who had inadequate training’ and that ‘observations were carried out but were insufficient to properly inform the observer whether Eliot was alert and breathing, or whether he was well’.

Staff last entered his room at 17:46 on 9^th April 2020. He was last seen conscious at 18:10. At 01:33 on 10^th April 2020, Eliot was found unresponsive. It was felt that he had been dead for several hours, and CPR was not attempted. A doctor pronounced Eliot dead at 02:00 on 10^th April 2020.

The inquest sought evidence from an expert pathologist and an expert endocrinologist. The experts were unable to reach a conclusion as to the medical cause of death on the balance of probabilities. They noted that an electrocardiogram would have assisted them in determining the cause of death, but this was not done. The jury were therefore directed to record the cause of death as unascertained, and to return an open conclusion.

The Coroner further indicated that she will prepare a Preventing Future Deaths Report highlighting several outstanding concerns about the provision of care by the Trust, including ongoing concerns about: the quality of observations; the method for allocating a nurse in charge; the quality of record keeping; ensuring care plans are complete and kept up to date; the need to ensure staff feel confident entering patients’ rooms in an emergency; and the need to ensure that, where an electrocardiogram or other physical health check has not been done, this is picked up more quickly.

Fosters has considerable experience in representing families at inquests across the country. If you have lost a loved one and would like to discuss the possibility of representation and how our team can help support your family – please contact us for a no-obligation chat on 01603 620508, or by email. More information is also available on our Inquests page.