Inquest finds neglect after patient dies from swallowing plastic crayon

A recent inquest has concluded into the death of a female patient who died after a plastic crayon she swallowed perforated her bowel.

The 36-year-old was a long-standing patient at the Rampton Secure Mental Health Hospital in Nottinghamshire, when she died back in June 2021, three months after she had been observed to swallow the pen by hospital staff.

Represented by Fosters Solicitors at the 10-day inquest at Nottingham Coroner’s Court, the family of the woman heard evidence that neglect had contributed to her death and there had been a gross failure to provide basic medical attention to the patient.

HM Area Coroner Laurinda Bower is due to issue a Prevention of Future Deaths (PFD) report following the inquest’s conclusion, and to write to numerous regulatory bodies including the Care Quality Commission, the General Medical Council, the Nursing and Midwifery Council and NHS England to highlight the issues identified.

Commenting on the inquest’s findings, the family of the patient issued the following statement: “We feel very let down by the staff and especially the doctor who were so called looking after our daughter at the time of her death.  It seems there were a lot of mistakes made by everyone at Rampton Hospital and a lot of warning signs that she needed proper hospital care. However, the staff and the health care trust just let her down by either ignoring or not listening to her, even when it was apparent she needed hospital treatment.  Because of this we have lost our daughter.  We hope this is a lesson learnt for any future cases.”

Jenny Fraser, our solicitor representing the family, added: “Patient T and her family have now sought the answers and justice they deserve.  It is disappointing that the most vulnerable people in our society, who rely completely on state run establishments to provide to them care and treatment, are suffering unnecessarily.  We hope that this investigation highlights to all establishments who have the responsibility of looking after those in need, to sit up and pay attention to ensure that they have the fundamental safeguarding and systems in place.  Preventable deaths need to stop happening.”

Fosters Solicitors 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.

The inquest of Patient T

Nottingham Coroner’s Court, 9-20 October 2023

An inquest has concluded into the death of a female patient who died on the 6th June 2021, after a 17cm plastic crayon that she had been observed to swallow by staff three months previously, perforated her bowel.

Background

Rampton Hospital is one of three high security mental health hospitals within England and Wales. Patient T was admitted to Rampton Hospital on 6 October 2016, having been detained within mental health settings of progressively higher levels of security since 2008.

Patient T arrived at Rampton with a diagnosis of Emotionally Unstable Personality Disorder. She presented with high and ongoing risk of self-harm. Her known risk factors for self-harm included swallowing foreign objects, occluding her airway as well as other unrelated risks.  She was opportunistic and persistent in her methods of self-harm. In response to these risks, risk assessments regularly authorised the use of mechanical restraints in Patient T’s care. These included the use of mittens and a bio belt where necessary, to restrict the movement of her arms and hands. Patient T was nursed under eyesight or arm’s length observations, with controlled access to items. The ingestion which had occasioned her death was done at a time when Patient T had access to large plastic crayons when her mittens were removed.  The inquest uncovered that the twistable crayon Patient T was observed to ingest on 22nd March 2021 by members of staff, could have been purchased at a shop located within Rampton Hospital whereby they stock such pens.

Circumstances of death

During post-mortem examinations, a 17cm plastic foreign object was located within Patient T’s peritoneum. Close to the site of the object was a 1cm tear in the small intestine, which had allowed bowel contents to leak into the abdomen, causing widespread infection. The object was found to be a twistable plastic crayon, of the type that Patient T was observed by staff to swallow on 22 March 2021.

Admissions made prior to final hearing

A few days before the inquest, but two years and four months since Patient T’s death, Nottinghamshire Healthcare NHS Foundation Trust made a number of admissions in relation to the management of Patient T’s risk of ingesting foreign objects:

• Staff were unclear about the number and type of objects that Patient T had swallowed.
• There was not a process in place to ensure that each object had been accounted for.
• Despite Patient T’s extensive history of ingesting items, staff had not considered the possibility that an intra-abdominal foreign body was the cause of Patient T’s physical deterioration.

The Trust further identified several delays in care which they admitted probably contributed to Patient T’s death:

“It is acknowledged by the Trust that the delay in investigating the reports of swallowing a foreign body object in April 2022, and subsequent delay in seeking medical attention and/or monitoring of this item and then providing a medical transfer to hospital on 5-6 June 2021 against the known background of high risk to ingestion of items has probably more than minimally contributed to her death at this time.”

Admissions made during the final inquest hearing

In oral evidence, the Trust conceded that they had made an error in their original admission. The Trust admitted that the delay in monitoring the twistable crayon began in March 2021, not April 2022 – a date subsequent to Patient T’s death.

The Trust made extensive further admissions throughout oral evidence.  In particular, the Deputy Director of Nursing admitted the following failings under examination from HM Area Coroner Laurinda Bower and Counsel for the family Patrick Cassidy:

• The twistable crayon provided to Patient T on 22 March 2021 had not been risk assessed and approved by the team responsible for her care plan, and therefore should not have been provided to Patient T.
• The Trust failed to have a formal policy in place in relation to the management of the ingestion of foreign bodies on or before March 2021.
• The Trust failed to have in place a care plan specified to Patient T’s risk of swallowing, despite this being a known high and ongoing risk on or before March 2021.
• The Trust failed to adhere to NEWS2 policy when Patient T was acutely unwell. (NEWS2 is national system for scoring physiological measurements in a patient).
• The physical healthcare team and the duty doctor failed to recognise that Patient T was a deteriorating patient over 5-6 June 2021, and failed to arrange a timely transfer to an acute hospital for treatment.
• There was a breakdown in communication between ward staff, physical healthcare staff, the duty doctor and site management as to Patent T’s symptoms, which led to a delay in her being transported to hospital for treatment.
• Once it was recognised that Patient T required treatment out of grounds, there was a delay in calling a medical emergency.

The Trust accepted that these multiple failings in Patient T’s care probably more than minimally contributed to her death.

The jury’s conclusion – finding of neglect

The jury in addition made a rare finding that neglect contributed to Patient T’s death. The finding of neglect in law reveals the jury were satisfied that there had been a gross failure to provide basic medical attention to Patient T, where she was in a dependent position, and where her physical condition showed that such attention was needed.  Although Rampton had a physical healthcare team, Patient T should have been transferred to hospital equipped to treat her acute physical condition far earlier.  She died within a short time of leaving Rampton after suffering a cardiac arrest in the ambulance on the way to Doncaster Royal Infirmary.

HM Area Coroner Laurinda Bower is due to issue a Prevention of Future Deaths (PFD) report following the inquest’s conclusion, and to write to numerous regulatory bodies including the Care Quality Commission, the General Medical Council, the Nursing and Midwifery Council and NHS England to highlight the issues identified.  During the evidence, HM Area Coroner made reference to the inquest into the death of Angus Bowie (a patient also at Rampton Hospital) held in 2019.  This investigation highlighted the need for staff to be properly trained in the use of NEWS2 in patient management. Sadly, this same issue arose in the inquest of Alex Braund.  Albeit in a prison context, this was another instance of failings found regarding the monitoring and adherence to NEWS2 for acutely unwell patients in a secure setting. Unfortunately, just over one year later, Patient T also tragically passes away, with the same issues arising regarding NEWS2 policies, clearly revealing that lessons have not been learnt within the Trust.

The family was represented at the inquest by Jenny Fraser, Charlotte Bishop and Jasmine Balmer of Fosters Solicitors and Patrick Cassidy, Counsel from Kenworthy Chambers, Manchester.

When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit samaritans.org to find your nearest branch.