Source · Prevention of Future Deaths

Terence Tuttle

Ref: 2021-0265 Date: 9 Aug 2021 Coroner: Yvonne Blake Area: Norfolk Responses identified: 1 / 2 View PDF

Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient care for mentally unwell patients refusing food, excluding family expertise.

Date 9 Aug 2021

56-day deadline 30 Sep 2021

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1.Lack of proper dietician assessment and mental health review at an early stage.
2.Inaction when Mr Tuttle was losing weight even though his intake was recorded no-one acted upon this.
3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act.
4.Inability to care for a mentally unwell patient with physical health problems, including gastric problems, who is refusing to eat.
5.Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation.
6. Apparent lack of recognition that serious harm did occur for this patient who was described as appearing cachexic.

Responses

1 respondent

Hellesdon Hospital NHS / Health Body

16 Aug 2021 PDF

Noted

NSFT expresses condolences and explains their limited involvement in Terrence Tuttle's care, stating they can only respond to one part of the coroner's concerns related to mental health liaison. They provide details of the mental health liaison team's involvement, assessments, and medication adjustments during his admission, highlighting communication and planned reviews. (AI summary)

View full response

Dear Ms Blake Re; Regulation 28 notification regarding the caro of Terrence Tuttle write In response IQ your loltor dalod 9" Auqusi 2021 ouliining Your concerns regarding the carc and treatment of Terrence whllst an mpalient al Ile Queen Elizabeth Hospital in Kings Lynn am very soty I0 near about the sad death of Terronce Should Inus lelter be shared with his famiy, woLld Iike t0 pass on my condalences t0 Inem Having reviewed the notification ain surprised Inis has come t0 Our Tnust have Ciscussed ing Kn col Jeagues at the Queen Elzabelh Hospital (QEH) to onsure wC do nol duplicate responses It is regretable Ihal We wefe nol asked l0 provlde Inlommalion o Ihe concern prior t0 the conclusion 0f the Inquest a5 understand we Were advised inal we werg nolan interesled pany am coni cent tnat we Kould nave Deen able t0 salisly your concern imned ately given Ine opportunity Out of the concerns Iisted below would advise thal NSFT arc aolc Io rcspond lo Ihe second part; in italcs af tre fIrst point only The oiner points would be Ior Ine QEH I0 respond t0] Lack of proper dietician assessment and mentol heanh review &an eany stege Inaction when Mr Tutle was losing weight even Inouoh h intake Was recorded no-one acted upon Uns Ability t0 assess Mr Tutlle adequately undcf Ine Mental Capacity Act Inability t0 care ior a mentally unwell patient wlh physical ncakh protrems, includirig gastric problems who is refusing t0 eat Refusal to include famiy members in caning tot (atter Over 20 years In 0 care homa) & patient who was in unfam | ar surroundings and tneir Delter knoxiledge of his usual prasontation Apparent lack 0f recogn bon that senous hamm did occur lor Ihes patient who was descnbed as appeanng cacherc may be heloful t0 ouuline Ine role of tne Menta' Healin Liaison Teams wihin our acute general hospials The team are & tnage assessment team and do not provide dreci 'hards on' card specilically In relalion t0 physca Inten cntons for example delry advice or nuintional balanca activines The leam wlll advise on mental ilness Symptoms diagnosis compassionate least restriclive Care ard de-eicalalion lechrques . The Ieamn pronoc both nursing and medical inout in relation t0 Irealmeni including psychotropic medication and monitonng wtulst the patient Is on (he acute ward may also arrange Ior tranaler t0 montol health ward once Ihe patient is physically it for discharge but requrres furthet suppor In relation Io Iheir menial wellbeing Where a capacity assessment IS required for a decision on @ physical healin issue 0r intervention, tne team may assist in respect 0f mental iIlness symptomalogy and the patentlal mpacl on # persons capaciy However the decision maker wli be tne physical health expen Tney

In Terrence 5 notes can see clear and regular communication between Ihe ward and tne Liaison Team, approximately hvo weeks post his admission the team were asked and attended the ward to assess Terrence; He was not able t0 participale Inis but the ward reported that he had been non-compliani win his anti-psychotic medication for approximately one week Although non-comoliant, Terrence was not aisplaying signs reporting symptoms 0l psycnosis Tne Liaison Teamn Jiscussed Ihis with the (eam Consuitant Psychiatrist who advised to stop the medication due to the time lapse; concentrate on improving his physical state and r@-assess.Iftne medication was reinstaled Inis would require Invasive moniloring procedures These measures were ith the caveal that if he deteriorated mentally t0 consider a Mental Health Act assessment for celention Tne ward contacted Ine team again 0n 1" March as Terrence had improved physically altnough still refusing food and fluidsHe was seen on 2rd March: the team concurred he was depressed and an anti-depressent was cominenced; Terrerce was dlscussed wilhln Ine daly team meeting and reviewed lace I0 face regularly, Terrence was commenced on Amisulpride oral Iiquid to treat any emerging psychotic symptoms and was complant with both meaications . The team nated an improvement in mental wellbeing on 10"" March albe t ne coniinued l0 reluse food and Iuids. Terrence was Iurther revlewed in respect ol his medicalions and presentation by Consuliant Psycha tnst on In March The team attended a bes; interests meeiing on 127 March where Ihe proposal was t0 move Terrence l0 2 nov nursing nome which could caler for his enhanced needs The community mental heallh care co-ordinator kept In contacl wlth Ihe ward and tne social worker, Ihe plan peing Inat once aischargeo tne Community Mental Healin Team wculd Teviewv Terrence nis net accomodalion: hope that this information satifies your concern:

Report sections

Investigation and inquest

On 07/04/2021 I commenced an investigation into the death of Terence Robert TUTTLE aged 65. The investigation concluded at the end of the inquest on 29/07/2021. The medical cause of death was: 1a) Frailty Syndrome 1b) Idiopathic Pulmonary Fibrosis and Schizophrenia 1c) 1d) Chronic Obstructive Pulmonary Disease The conclusion of the inquest was: Mr Terence Tuttle was admitted to hospital after testing positive for covid in January 2021. He usually resided in a care home, had known mental health illness but had been stable on anti-psychotics for many years. He was treated appropriately for acute kidney injury and pneumonia and had food and fluid record charts. Despite these demonstrating poor oral intake no prompt action was taken. It was after a review by the mental health liaison team that decisions were taken relating to nutrition and diet. Mr Tuttle had lost a significant amount of weight which contributed to his poor condition post covid. He had also been found to have a bleeding duodenal ulcer and complained about his stomach being uncomfortable. He was transferred to a different nursing home after a best interests meeting was held which decided that he had capacity to risk feed. He died 3 days later at the nursing home.

Circumstances of the death

Mr Tuttle lived and was cared for in a care home. He had a longstanding diagnosis of schizophrenia which had been stable for many years on anti-psychotic medication. In January 2021 he was admitted to a general hospital a week after testing positive for Covid-19. On admission he had an acute kidney injury which was treated, and pneumonia. He was also found to have a bleeding duodenal ulcer for which he received a blood transfusion and a proton pump inhibitor. He had been complaining of abdominal discomfort. He had diet and fluid record charts which demonstrated that he was not having adequate oral intake. Nothing was done about this and he lost 10kgs in weight over a 3-week period.

He had a mental health review and was prescribed antidepressants. It appears some encouragement to take food and fluids was made but he was not seen promptly by the dieticians and he was weakened and malnourished when he was assessed. He was not felt to have capacity to refuse food initially, but this opinion was changed later. Mr Tuttle was also refusing medication including anti-psychotics. His family were refused permission to visit. They had offered to come and try to persuade him to eat. By the time he had been properly assessed he was weak after his pneumonia and lack of adequate food and fluids. His appetite was gone, and he continued to refuse food. A best interests meeting was held, and it was agreed he had capacity and could risk feed since he refused naso gastric feeding. A new nursing home placement was found because he had increased care needs and he was transferred there approximately 50 miles away from his family who had always been involved in his care. He died 3 days later. The hospital conducted an investigation but concluded no major harm occurred to the patient due to lack of care. Their recommendations included actions which should already be in place as a matter of common sense and do not address at all the difficulties in looking after a mentally unwell patient in an acute setting. There were no prompt MH or dietician assessments. There was confusion/lack of knowledge around The Mental Capacity Act and associated paperwork. There was no focussed consistent approach to his overall care and symptoms.

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Report details

Reference: 2021-0265
Date of report: 9 August 2021
Coroner: Yvonne Blake
Coroner area: Norfolk

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 30 Sep 2021.

Sent to

Hellesdon Hospital

Queen Elizabeth Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.