Neglect Contributed To Death Of Volodymyr Korol At Shrewsbury Court Independent Hospital, Inquest Concludes
”It is, without doubt, the worst management of a cardiac arrest I have ever come across”
The inquest into the death of 35-year-old Volodymyr Korol concluded today, finding that there were multiple failings by the Trust and a conclusion was given that Volodymyr’s death was contributed to by neglect.
The Inquest was heard at Surrey Coroner’s Court before HM Coroner, Anna Crawford.
Mr Korol was originally from Ukraine and was physically and mentally healthy before coming to the UK in 2002.
Mr Korol developed mental health problems shortly after his arrival in England, which deteriorated and a series of hospital admissions followed. In 2015, he was placed in Shrewsbury Court Hospital, Redhill, Surrey, owned by the Whitepost Group, and detained under Section 3 of the Mental Health Act. Over a period of time, Mr Korol also developed several physical health conditions including Type 2 Diabetes, Sleep Apnoea and Obesity.
At the time of his death, Mr Korol should have been being observed every 15 minutes by staff due to growing concerns about his physical health and in particular his breathing. The purpose of monitoring so frequently was to ensure early detection of any respiratory problems and allow for a prompt intervention. On August 1st, 2020, Mr Korol died following an unwitnessed cardiac arrest and failed resuscitation. It appears that the nurse in charge had deliberately falsified observation records throughout the night, recording that 15 minute observations had been conducted when they had not.
Mr Korol’s family, led by his grieving mother, Mrs Halyna Korol, gave evidence which made it clear that she had raised ongoing concerns about Mr Korol’s deteriorating physical and mental health throughout his inpatient stay, which were ignored. She was particularly concerned with the level of checks that were performed on the night that he passed away, staffing levels, and what appears to have been the incompetence of hospital staff when faced with an emergency.
Despite the easing of Covid restrictions, Mrs Korol, was turned away from the hospital and refused access to see Mr Korol when she tried to see him for his birthday on 1 July. She continued to be turned away during the month of July when she tried to visit him on numerous occasions. The last time she saw her son alive was in March 2020. Mr Korol died at Shrewsbury Court Independent Hospital on 1st August 2020.
In a report commissioned by the coroner, independent cardiologist, Dr Khan, stated: “Mr. Korol’s death could’ve been prevented”, and that the staff’s actions at the hospital “were entirely inadequate and inappropriate and that they followed no resemblance to any recommended response or guidelines for cardiac arrest or CPR”. He went on to say “Aside from not checking him every 15 minutes to ascertain his well-being, even after he was found to be in cardiac arrest it took perhaps 12.5 minutes for CPR to be commenced and this was done badly”. In addition, there was a complete failure of staff to use the defibrillator.
Dr Khan concludes “It is, without doubt, the worst management of a cardiac arrest I have ever come across”.
The post mortem report identified several causes of death, including the cardiac condition ischaemic cardiomegaly. The extent and nature of Mr Korol’s cardiac illness had not been properly identified nor treated during the time he was alive. Not only did Dr Khan find that Mr Korol’s death could have been avoided had he been properly resuscitated on the night of his death, but he also found that his chances of survival would have been significantly higher had the condition been properly identified and treated prior to death.
Internal reviews at Shrewsbury Court Independent Hospital highlighted problems within the hospital and in the treatment afforded to Mr Korol on the night of his death, in particular in relation to the failure of staff to undertake checks every 15 minutes and the reduced number of staff to only one on a ward for 2 hours and 45 minutes. Despite this, the conclusion of the review stated that CPR could not be conducted because of his weight. There has been a complete lack of acceptance of either responsibility or accountability by the hospital or the individual staff members involved.
Shrewsbury Court Independent Hospital has since closed its doors on December of 2021 following an inspection by the care quality commission in August 2021.
Halyna Korol, Mr Korol’s mother said: “The hospital my son was in was more like a high-security prison. He was admitted to the hospital as a mentally ill person and developed significant physical illnesses. The treatment he received was totally inadequate and inappropriate.
“I trusted the doctors, I gave them responsibility for my son’s care and expected him to be cared for properly. They let both my son and me down. They took away my son’s future and ruined my life.
“I realise now that my son will never come back, but I hope that what we are doing now is a big step forward to help other patients who may be in his situation.”
Nina Ali, Partner and Medical Negligence Solicitor at Hodge Jones & Allen, representing Halyna Korol, said: “Mr Korol’s case is shocking – a vulnerable patient supposedly on a schedule of 15 minute monitoring should not experience an unwitnessed cardiac arrest. Mr Korol’s family were entitled to assume that he was safe in the care of professional staff, but instead, as the report from the independent cardiologist outlines, he was subjected to the ’worst management of cardiac arrest’, that he had come across in his 30 years of experience.”
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