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Inquest finds ‘gross failure’ in death of 33-year-old man with Downs Syndrome

The inquest into the death of 33-year-old Richard Handley from Lowestoft in Suffolk concluded today with a finding of gross failure to the actions of Ipswich Hospital, part of the Norfolk and Suffolk NHS Foundation Trust.

In his narrative conclusion, HM Senior Coroner for Suffolk, Dr Peter Dean, found that changes to Richard’s diet and the decreased monitoring of his bowel movements at his care home contributed to his worsening constipation and resultant faecal impaction, without which Richard’s death would not have occurred.

He went on to find gross failure on behalf of Ipswich Hospital in responding appropriately to Richard’s increased MEWS scores (modified early warning scores) when he was in hospital for surgery to deal with his illness. These are designed to flag any deteriorating changes in a patient’s condition.

Consequently, Richard did not receive the appropriate level of input from the surgical team or benefit from the expertise of the critical care team that he should have done, and so there was a missed opportunity to provide potentially life-saving interventions.

Richard Handley died on 17 November 2012 at Ipswich Hospital. He had Downs Syndrome and, at the age of 18, developed mental health difficulties. Throughout his life, part of his care had involved careful monitoring of diet and bowel movements because Richard was suspected of suffering Hirschsprungs Disease, a condition causing chronic constipation.

Until the age of 19, Richard lived with his family and then, in September 1999, a place was found for him at a residential care home, Bonds Meadow, Lowestoft. A care plan was devised, with input from his family, his diet was regulated and his carers diligently monitored his general health and, specifically, his bowel movements.

In 2010 the status of the care home changed, and whilst this should not have affected the care that Richard received, it would seem that, unknown to the family, this knowledge of his specific care needs was lost and that careful monitoring was not in place.

Due to lack of careful monitoring of his condition, Richard developed severe constipation and, in November 2012 his abdomen had become so distended as to require surgery at Ipswich Hospital to remove 10kg of faeces.
Unfortunately, post-surgery Richard’s condition deteriorated further and on 17 November, he died from a cardiac arrest.

At post-mortem it was found that his bronchi and nasal passages contained gastric contents and that it was likely that death was through aspiration of his vomit, due to a bowel obstruction.

Sheila Handley, Richard’s mother, says: “Given the evidence we’ve heard in court, and the gross failures and missed opportunities noted, we are profoundly disappointed that the coroner felt unable to make a finding of neglect.

“The Coroner did, however, recognise that without our diligence and persistence many of the reviews into Richard’s death would not have occurred and the inquest would not have been able to explore the extent of the failings in his care. Richard was wholly reliant on health and social care services to exist, and now he doesn’t.

“We will now take time to digest what we’ve heard today and consider next steps with our lawyer, Nina Ali.”

Nina Ali, a medical negligence partner at London law firm Hodge Jones & Allen, who has been acting for Richard’s family said: “I echo the family’s disappointment at today’s findings.

“Given the weight of evidence presented, it is difficult to understand how the failure to deliver Richard the package of care he required was not neglect. We will now spend some time considering our next steps.”