The purpose of a Coroner’s Inquest is to examine four questions where there has been an unexplained or unnatural death.  Namely, who was the deceased, when where and how did they die.  Although the Coroner’s Court is a Court of inquiry and not blame, it is important that care providers understand the potential consequences of the inquest conclusion, particularly if this conclusion includes reference to the death having been contributed to by neglect.

A finding of neglect has serious repercussions in terms of reputational damage as well as potential criminal and/or civil proceedings with additional financial implications.  A recent Inquest highlights the steps care providers should take to avoid this outcome.

The Inquest

The Inquest considered the death of James Pollard, a 36 year old man who had been detained under section 3 of the Mental Health Act in a medium-secure psychiatric unit.

On 28 April 2013 he was found by staff in his en-suite bathroom with the electric cable of a CD player around his neck.  He was taken to hospital and died on 1 May 2013.

There were a number of warning signs which staff should have taken into account:

  • he was known to conceal symptoms from staff and act without warning
  • he had already tried to strangle himself twice since his admission to the unit in February 2013 and was on a 10 minute observation level whist in his bedroom
  • his care plan specified he was only allowed access to a CD player and cable during the day and was not allowed it if he presented as unsettled or voiced thoughts of self-harm
  • on 26 and 27 April his parents reported that he was exhibiting signs of paranoia similar to before a previous suicide attempt and
  • on 28 April his medical notes recorded that he reported feeling paranoid, having “racing thoughts” and sleeping badly.

Despite these warning signs, his care plan was not changed and he was allowed access to the CD player and cable.

The Inquest into his death held on 17 – 19 March 2014 found that he “took his own life, while the balance of his mind was disturbed, which was contributed to by neglect”.

A finding of “neglect” in an Inquest is rarely used and considered to be very serious given that the purpose of Inquests is a fact finding exercise and is not to establish blame.

The test for neglect is that, on the balance of probabilities, the following points can be established:

  1. the deceased was in a dependent position where he could not provide for himself and
  2. there was a gross failure, that is one which was substantial and not trivial, to provide basic medical attention and
  3. the gross failure led to or contributed to the death.

There is no definition of what constitutes a “gross failure” but case law has established that it can include errors of judgment as well as direct acts or omissions.

Implications for providers

This case raises a number of important considerations for providers, the main of which are set out below:

  • information/warnings given by relatives must be taken into account and given the necessary weight
  • the provisions of a care plan must be adhered to
  • consideration must be given as to whether more should be done to assess and manage risks
  • observation level policies should be reviewed and
  • anchor points should be reviewed on an ongoing basis.

What to do next?

A finding of neglect has serious repercussions in itself in terms of reputational damage and may be followed by criminal and/or civil proceedings with additional financial implications.

A neglect finding often indicates systemic failings and a case such as this is a timely reminder of the importance of reviewing policies and procedures in relation to risk assessment and management, observations, communications with relatives and adherence to care plans.  It also highlights the need to ensure that staff receive regular training and supervision and this training is followed.