This article was first published in the November AvMA newsletter.
Nigel Handscomb was a 65 year old gentleman with a history of bipolar disorder, which was managed well with lithium. On the 18th August 2017, Mr Handscomb visited his GP surgery, presenting with a history of dysphagia and vomiting which had lasted several days. Later that evening, he was not contactable and his family raised the alarm. He was taken to the Accident & Emergency Department of University Hospital Lewisham, where he was diagnosed with pneumonia and a possible stroke. He was transferred to a ward on the 19th August 2017 to continue treatment.
Mr Handscomb sadly passed away on the 21st August 2017. The investigations that followed his death revealed a series of failures in the management of his care by both the hospital staff and his GP. The Coroner concluded that neglect had contributed to Mr Handscomb’s death.
Mr Handscomb had a history of bipolar disorder. He managed his condition well with lithium, which he had been prescribed for a number of years.
Mr Handscomb visited his GP surgery on the 7th July 2017, following a blood test. Dr Neve noted that his lithium level was slightly raised and his renal function had deteriorated. Dr Neve subsequently reviewed Mr Handscomb on the 7th August 2017. His lithium level remained unchanged, albeit still slightly raised, however his renal function had returned to its previous level. Mr Handscomb’s lithium dosage was subsequently reduced.
On the 18th August 2017, Mr Handscomb saw Dr Gramsma at his GP surgery. He presented with a history of severe dysphagia, which had resulted in him bringing up fluids and “giving up” with solid foods. Dr Gramsma prescribed lansoprazole and advised Mr Handscomb to return on the following Monday.
Later that evening, at approximately 22:15, paramedics attended Mr Handscomb’s residence due to his family’s concerns that they were unable to reach him. Mr Handscomb was discovered by the kitchen sink with his head resting on the tap, immersed in cold water. He was transported to the Accident and Emergency Department of University Hospital Lewisham in an unwell and confused state. He was recorded as having a history of vomiting over the previous few days. He was diagnosed with pneumonia and concerns were raised as to a possible stroke. Treatment in the form of IV Amoxicillin, oral lansoprazole and oral clarithromycin was given.
Prior to his admission to a ward, Mr Handscomb should have been placed on a list of patients for a Consultant to see him in the post-take ward round. As a result of an error by a junior doctor managing patient admissions, this was not done. Mr Handscomb was therefore not reviewed by any doctor until his death on the 21st August 2017.
Mr Handscomb was transferred to Laurel Ward on the 19th August 2017. No observations of Mr Handscomb were taken by the nursing staff after his admission for a period of 11 hours. Once observations were taken, no referral to the outreach team and senior nurse was made when his NEWS (National Early Warning System) scores reached the appropriate level for intervention. Thereafter, his NEWS scores were incorrectly recorded.
Mr Handscomb was determined to be nil by mouth by the nursing staff following a swallow assessment. Fluids were prescribed to him by a doctor, however the doctor wrote the prescription without ever reviewing Mr Handscomb. At numerous nursing handovers, it was not identified at any point that Mr Handscomb had not been seen by a Consultant. Further, as Mr Handscomb took lithium for his bipolar disorder, Trust policy indicated that his lithium levels should have been taken upon his arrival at the hospital. No lithium levels were ever taken, and therefore, it could not be determined whether Mr Handscomb was suffering from lithium toxicity prior to his death.
Mr Handscomb was discovered in the early hours of the 21st August 2017 in cardiac arrest. He could not be successfully revived. A post-mortem later indicated that the cause of death was:
1(a): aspiration pneumonia;
The inquest was heard in Southwark Coroner’s Court before Assistant Coroner Philip Barlow over two days. Evidence was heard from the family, Mr Handscomb’s general practitioners, and the clinicians and nurses involved in Mr Handscomb’s care at University Hospital Lewisham.
It transpired in the course of the inquest that the nursing staff had determined shortly after his admission to Laurel Ward on the 19th August 2017 that Mr Handscomb could not swallow effectively. His oral medication, including clarithromycin, was stopped. No referral was made to any clinician to notify them that the medication for Mr Handscomb’s pneumonia had been stopped, nor were any questions raised as to how the clarithromycin could be administered in any other way. Mr Handscomb’s pneumonia was therefore ineffectively treated until his death two days later.
It further transpired that Mr Handscomb’s GP, Dr Gramsma, was not properly recording the outcomes of patient consultations following appointments. These records of his consultations were being produced some time later, and subsequently, a number of crucial details (including in this case whether Mr Handscomb had been physically examined), were omitted.
The Coroner provided a short form conclusion with narrative elements. He considered that several opportunities to escalate Mr Handscomb’s care were missed. He found that there were gross failures to provide care to Mr Handscomb, who was in a dependent position. He noted that the evidence of Dr Aitken was that if Mr Handcomb’s care had been escalated, he would have been reviewed and likely a candidate for intensive care. As such, on the balance of probabilities, he would have survived.
The Coroner was satisfied that University Hospital Lewisham had made important changes since Mr Handscomb’s death and did not consider a Prevention of Future Death report in respect of the hospital was appropriate.
The Coroner was however critical of Dr Gramsma’s record keeping. He noted that the records referred to in the course of the inquest were made several hours after Mr Handscomb’s consultation. They did not record that he performed a chest examination, nor that Mr Handscomb had not been able to take his lithium for several days, contrary to the evidence of Dr Gramsma. The Coroner noted that it was a significant finding that Mr Handscomb could not swallow, yet there was no record of this in the medical record entry recorded by Dr Gramsma. No record was made that the medication prescribed to Mr Handscomb during that consultation was not to be taken in accordance with the instructions written on the medication packaging.
The Coroner accepted that the care offered by Mr Handscomb’s GPs did not have a causative impact, however thought that the concerns could be highly significant in another case. Consequently, he considered a Prevention of Future Death report in respect of Dr Gramsma was appropriate.
Following the decision of the High Court in R (Parkinson) v HM Senior Coroner for Kent  EWHC 1501 (Admin), families will face challenges in demonstrating that Article 2 ECHR is engaged, as cases have to be considered exceptional and go beyond mere error or medical negligence. In this case, the Coroner did not consider that Article 2 ECHR was engaged; rather, it was a case that fell into the category of errors of care, coordination and delay. Despite this, the Coroner was nonetheless critical of the care Mr Handscomb received, leading to a finding of neglect.