Source · Prevention of Future Deaths
Darren King
Ref: 2020-0090
Date: 6 Apr 2020
Coroner: Nigel Parsley
Area: Suffolk
Responses identified: 0 / 2
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There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.
Date
6 Apr 2020
56-day deadline
2 Jun 2020
Responses identified
0 of 2
Coroner's concerns
There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.
View full coroner's concerns
the MATTERS OF CONCERN as follows. –
In Darren’s case it was clear that due to his learning disability and autism, engagement with him could be difficult.
However, the following three areas of concern were identified.
1. The lack of effective follow up action when a patient with learning disabilities disengages, especially when they are a high-risk patient (such as Darren).
2. The lack of a clear escalation process when an increased risk is identified and this risk cannot be easily addressed (as it was in Darren’s case).
3. The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral/escalation routes should they have a concern.
In Darren’s case it was clear that due to his learning disability and autism, engagement with him could be difficult.
However, the following three areas of concern were identified.
1. The lack of effective follow up action when a patient with learning disabilities disengages, especially when they are a high-risk patient (such as Darren).
2. The lack of a clear escalation process when an increased risk is identified and this risk cannot be easily addressed (as it was in Darren’s case).
3. The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral/escalation routes should they have a concern.
Report sections
Investigation and inquest
On 3rd August 2017 I commenced an investigation into the death of Darren Edward KING
The investigation concluded at the end of the inquest on 24th February 2020. The conclusion of the inquest was that the death was the result of:-
Darren King died as the result of an accidental death following an epileptic seizure whilst in his bath.
The medical cause of death was confirmed as:
1a Drowning 1b Epileptic seizure
The investigation concluded at the end of the inquest on 24th February 2020. The conclusion of the inquest was that the death was the result of:-
Darren King died as the result of an accidental death following an epileptic seizure whilst in his bath.
The medical cause of death was confirmed as:
1a Drowning 1b Epileptic seizure
Circumstances of the death
Darren King died on or before the 8th April 2017 at his home address of Dell Road East, Lowestoft in Suffolk.
When found by his mother, late on the 8th April 2017, Darren was unresponsive with his head under the water in the bath. Darren had a known history of epilepsy, autism and learning difficulties. Following his death, a post-mortem examination concluded that Darren’s medical cause of death was drowning as the result of an epileptic fit.
At the time of his death Darren was under the care of Suffolk County Council Adult and Community Services, the Norfolk and Suffolk Foundation Trust and his local General Practitioner. Because of the complexity of Darren’s case he was on a multi-disciplinary/agency CPA (Care Plan Approach) the management of which was undertaken by a care co-ordinator. When the CPA was commenced, it was documented that the agencies involved were aware of the significant risk bathing posed to Darren, due to his epilepsy. Darren had an identified poor record for attending both medical and social care meetings, however his poor attendance increased after June 2016. This increased lack of engagement appeared to have coincided with staff changes and a new management responsibility for a newly designated care co-ordinator. The last contact his care coordinator from the Norfolk and Suffolk Foundation Trust had in person with Darren was in June 2016. In September 2016 Darren saw his GP. At this time Darren was having seizures up to three times a week (previously Darren had suffered from these approximately three times per month). Darren’s epilepsy medication was increased, and he was told he needed a further epilepsy treatment review in three weeks time. This was the last reported contact with a medical or mental health professional regarding Darren’s epilepsy treatment plan and, although seen by support workers from other CPA agencies, there was no further contact made with him by medical or mental health professionals in the 6 months leading up to his death. As a result of this lack of contact, there was no opportunity to review Darren’s epilepsy treatment regime and no opportunity to effectively monitor his seizure history. On a balance of probability basis had opportunities to provide adequate monitoring and treatment relating to Darren’s epilepsy been taken, then his death may have been prevented.
When found by his mother, late on the 8th April 2017, Darren was unresponsive with his head under the water in the bath. Darren had a known history of epilepsy, autism and learning difficulties. Following his death, a post-mortem examination concluded that Darren’s medical cause of death was drowning as the result of an epileptic fit.
At the time of his death Darren was under the care of Suffolk County Council Adult and Community Services, the Norfolk and Suffolk Foundation Trust and his local General Practitioner. Because of the complexity of Darren’s case he was on a multi-disciplinary/agency CPA (Care Plan Approach) the management of which was undertaken by a care co-ordinator. When the CPA was commenced, it was documented that the agencies involved were aware of the significant risk bathing posed to Darren, due to his epilepsy. Darren had an identified poor record for attending both medical and social care meetings, however his poor attendance increased after June 2016. This increased lack of engagement appeared to have coincided with staff changes and a new management responsibility for a newly designated care co-ordinator. The last contact his care coordinator from the Norfolk and Suffolk Foundation Trust had in person with Darren was in June 2016. In September 2016 Darren saw his GP. At this time Darren was having seizures up to three times a week (previously Darren had suffered from these approximately three times per month). Darren’s epilepsy medication was increased, and he was told he needed a further epilepsy treatment review in three weeks time. This was the last reported contact with a medical or mental health professional regarding Darren’s epilepsy treatment plan and, although seen by support workers from other CPA agencies, there was no further contact made with him by medical or mental health professionals in the 6 months leading up to his death. As a result of this lack of contact, there was no opportunity to review Darren’s epilepsy treatment regime and no opportunity to effectively monitor his seizure history. On a balance of probability basis had opportunities to provide adequate monitoring and treatment relating to Darren’s epilepsy been taken, then his death may have been prevented.
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Report details
- Reference
- 2020-0090
- Date of report
- 6 April 2020
- Coroner
- Nigel Parsley
- Coroner area
- Suffolk
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Jun 2020.
Sent to
- Adult and Community Services Suffolk County Council
- Norfolk and Suffolk NHS Foundation Trust