Coroner finds systemic failings led to mental health patient's death

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Coroner finds systemic failings led to mental health patient's death

3rd July 2013

The family of a man who died whilst under the care of a specialist mental health hospital has called for a Public Inquiry after a fresh inquest heard their son’s death was a result of systemic failings.

William 'Bill' Johnson, 41, died on 31 May 2011 at St Andrew’s Hospital in Northampton from complications caused by a severe bowel obstruction which had developed over a number of months – a recognised side-effect of the antipsychotic medication he had been prescribed with a known risk of fatality if undetected.  A previous inquest verdict was overturned after the coroner for Northamptonshire accepted that her original inquiry did not comply with the requirements of the Human Rights Act 1998.

HM Coroner for Milton Keynes Mr Tom Osborne today (3 July) recorded a narrative verdict at the inquest into the death of Mr Johnson. The inquest heard how in the weeks before his death, Mr Johnson - a patient detained at St Andrews for 18 years under the Mental Health Act - had left a physical examination before it had been completed. But not only did staff fail to ensure the examination was concluded at a later date, but they also failed to even make a note that the original examination was never finished. As a direct result, a severe bowel obstruction that led to Mr Johnson’s internal organs effectively shutting down was never identified or treated, leading to his painful death.

Delivering his verdict, Mr Osborne said: “An annual physical systemic examination recorded that no abnormal findings had been detected and had not recorded in his medical notes and records that the examination could not be completed because of his non co-operation.

“Clinical and nursing staff were not aware that it had not been completed. His bowel movements were not monitored and the serious nature of his condition was not recognised which resulted in a lost opportunity to successfully treat his condition.”

The Coroner’s investigation confirmed that, prior to Mr Johnson’s death, three other patients had died on the same ward over a seven month period for causes potentially similar to Mr Johnson.

The inquest raises a number of issues going to the reporting of deaths of detained patients, the role of the Care Quality Commission and indeed whether the original coroner had available to her details of the previous deaths.

Some of those issues are currently under review by the Coroner of Northamptonshire and the Care Quality Commission. When expressing his sympathies to the family, the Coroner was keen to assure them that their son’s death was likely to assist and help patients such as William, who are at risk of physical ill health by reason of the high dose psychiatric medication that is prescribed to them.

Speaking after the hearing, Mr Johnson’s father Bert said: “We are very satisfied with the result of the inquest, and we would like to thank the Coroner for his sympathetic concern for ourselves.

“The case illustrates the vital importance of monitoring and treating the physical needs of mental health patients,” he said. “We hope and expect this lesson to be more widely understood and appreciated by those responsible for these patients’ care.”

Etala Anderson of Fentons Solicitors, representing Mr Johnson’s parents, said the evidence presented at the inquest had revealed ‘a whole host of issues.’

“We intend to immediately raise these issues with the relevant various third parties,” said Mrs Anderson. “In our view, these issues go well beyond the remit of an individual inquest. That is why we will be pursuing the possibility of a Public Inquiry into the circumstances of these deaths over such a short period of time.”

Media coverage of this case:The Observer ITV, Northampton Chronicle