Ronald Ashdown

Notwithstanding the finding of a natural cause of death, inquest evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. 1. Upon RA’s arrival back at the Nursing Home on 2nd August, staff immediately raised a Safeguarding concern in respect of, inter alia, his genitals being covered in a white “cheese” like substance with, additionally, faecal matter in his pubic hair; extensive areas of flaking skin including behind his ears was also identified. Colour photographs were taken and provided to the Trust along with the Safeguarding documentation. Objectively, the photographs clearly documented the flaking skin and white “cheese” like material covering RA’s penis.

2. Evidence confirmed that the Mid and South Essex NHS Foundation Trust, responsible for Basildon Hospital, carried out a significantly flawed RCA investigation which effectively rejected any suggestions of shortcoming in care, management and treatment. The Ward Matron (responsible for the ward concerned) was the co-author responsible for the RCA Report. gave evidence to the inquest that she had not been provided with the photographs provided by the Nursing Home and RA’s daughter until just two weeks prior to the inquest hearing. (It was noted and accepted that even when had seen the photographs neither nor the Trust had seen fit to draw this to HMC’s attention or to provide either an addendum statement or a revised RCA).

3. The Trust’s responsible Adult Safeguarding Lead provided a statement in which confirmed that, notwithstanding the photos having been expressly noted in the original Safeguarding referral and raised in subsequent correspondence and meetings with the Thurrock Local Authority Safeguarding Team, had not made the photos available for the purposes of the RCA. was unable to provide any explanation at all for this failure. This lack of professionalism was and remains a grave cause for concern resulting as it did in a seriously flawed Trust investigation, which itself fed into the Thurrock Adult Safeguarding investigation and, further still, a wider section 42 systemic investigation involving RA’s case and two others to which a range of stakeholders contributed. It was accepted by the Trust witnesses that but for the coronial investigation, the denials of any Trust failings would have remained unchallenged perpetuating a false record of the basic nursing care provided (or not provided) to the highly vulnerable and dependent RA.

4. The evidence heard at the inquest undermined the following erroneous findings of the RCA:

• In response to the concern that RA had extensive flakes of fungal growth behind his ears the RCA concluded that “no flakes noted in hospital, documentation supports regular personal care was provided throughout admission.”

• In respect to the concern that RA’s foreskin/genitals were covered in flakes and what appeared to be “cheese / paste” the RCA asserted that there were “no flakes noted in hospital, documentation support regular personal care was provided throughout admission.”
• In response to the concern that RA’s pubic hair contained dried faecal matter the RCA asserted that “documentation (was) found to support (RA) had a full wash on day of discharge back to nursing home.”

5. Having belatedly considered the photographs, the Ward Matron retracted her investigation findings and conceded that for RA’s genitals to have appeared as they did in the photographs (taken on the day of his arrival back at the Nursing Home) he would have had to have received “no basic nursing care in the form of the washing of his genital area for several days”. , and the Trust, were obliged to accept that the nursing records purporting to claim that RA “had a full wash on the day of discharge” was demonstrably untrue and that, in fact, he had not been washed fully for many days. The extensive areas of flaking skin behind RA’s ears were also, contrary to the RCA finding, now accepted.

6. My principal focussed concerns are therefore:

(a) The extent of the Trust’s inexplicable failure to provide critical primary evidence for the purposes of the RCA led directly to an erroneously exculpatory RCA Report; without an accurate and reliable RCA the lessons upon which important changes to Trust systems and practice depend cannot be identified and acted upon in a timely fashion;

(b) The evidence confirmed that, despite his clear vulnerability and complete physical dependence on Trust staff providing basic nursing care, including simple personal hygiene, RA did not receive such basic care for an extended period – probably over several days. This does not indicate, as appears to have been suggested at one point by the Trust, a failure in record keeping but, rather, a serious failure in the provision of the most basic of nursing care. Running as it did over several days, the evidence confirmed that this failure to provide basic care likely extended beyond one or two members of staff and, further, was simply not picked up by the more senior nurses on the Ward.

(c) Although the failure to provide such basic nursing care, in the specific context of RA’s identified cause of death (and notwithstanding his vulnerability to infection), had no causal relevance to his death, I am nonetheless entirely satisfied that in myriad other cases the identified failure of this kind gives rise to the obvious risk of infection and consequently the risk of future death.

(d) Finally, the evidence confirmed that the misleading failures in the Trust’s RCA fed into and undermined the subsequent Thurrock Local Authority Safeguarding Adult Review Investigation and a wider systemic section 42 Safeguarding investigation, both of which will now require review with the concomitant delay involved.