The assistant West Sussex coroner Michael Burgess held an inquest yesterday, 29 April 2014, on the circumstances leading up to the death of a Chichester woman, Janet Blackman, aged 66, in May 2013 at St Richard’s Hospital in Chichester. In his verdict he identified a lack of coordination in the medical and psychiatric treatment she received which was provided across two hospitals and two different NHS trusts (Western Sussex Hospitals NHS Trust and Sussex Partnership NHS Foundation Trust) after hearing evidence that her death could have been avoided if further investigations had been carried out into her medical condition.
He expressed particular concern at the risks raised where patients with overlapping medical and psychiatric conditions cannot have both aspects treated at the same hospital or even the same NHS trust and advised that he would be raising this issue further with the trusts involved and the Secretary of State for Health.
Mrs Blackman was admitted to St Richard’s Hospital on 20 May 2013 with a sudden onset of confusion. Initial assessment and testing revealed some medical abnormalities including hypo-thyroidism. On 25 May 2013 she was transferred to the Harold Kidd psychiatric unit in Chichester because of concerns about her ability to make decisions about her own care. At this stage there was still not a clear picture about her medical condition.
The following day Mrs Blackman was found collapsed on the floor. She was taken to A&E at St Richard’s. A decision was made to conduct X-rays and blood tests and if these were normal, to return her to the Harold Kidd Unit. No steps were taken to investigate the cause of her collapse or her documented low oxygen saturation and tachycardia. The testing was assessed as not showing any results of concern – although in fact some of the blood results did reveal abnormalities.
Mrs Blackman was transferred back to the Harold Kidd Unit on 27 May. Two days later she suffered a further form of collapse and was returned to A&E at St Richard’s. They proceeded on the basis that she had suffered a cardiac arrest but were unable to save her. A subsequent post mortem confirmed her cause of death as bilateral pulmonary embolism.
Following Mrs Blackman’s death, a number of investigations were undertaken. The West Sussex coroner Mrs Penelope Schofield determined that an inquest hearing should be held and the Western Sussex Hospitals NHS Trust carried out a full internal investigation.
These two routes flagged a number of concerns about Mrs Blackman’s care from the time of her first admission including a failure to investigate and manage her medical condition properly, to monitor and address the physical impact of issues with her eating, drinking and taking of medication, inadequate communication between the medical and psychiatric teams, a failure to investigate properly the cause(s) of her fall on 26 May 2013 and her inappropriate return to the Harold Kidd Unit on 27 May.
The coroner heard evidence from a number of individuals regarding Mrs Blackman’s case. It was clear that a group of people were involved in her care and that the full picture was not always considered. It was specifically highlighted that a review of all the information available would have resulted in further investigations being carried out following the collapse on 26 May and that the view of the coroner’s expert was that this should have happened and would have been likely to result in diagnosis and successful treatment of the pulmonary embolisms.
The Blackman family were represented at the inquest by Philippa Luscombe, partner in the clinical negligence team at Penningtons Manches LLP, and Martyn McLeish of Cloisters Chambers.
Commenting after the inquest, the Blackman family said: “The sequence of events from the time of Janet's admission were deeply distressing and her loss was a huge shock to us all. We were concerned at the time about the care that she received, the communication and the focus being too much on her psychological rather than her medical and physical condition.
“Since her death, the hospital has carried out a full investigation and we appreciate its thorough handling of this and its openness with us as a family. The coroner also undertook a detailed inquiry before the matter was passed to Mr Burgess and we now have a much better understanding of what occurred. We hope that the outcome of the inquest will be that other patients in a similar scenario will receive better and more coordinated care.”
Philippa Luscombe commented: “From the evidence that we have seen, we believe that there were failings in the medical care provided to Mrs Blackman and that her death was avoidable. Mrs Blackman’s family have been concerned about her treatment and have appreciated the comprehensive investigations by the coroner and the trust responsible for St Richard’s Hospital which have enabled them to get a better understanding of what happened and what can be done to prevent a similar situation in the future.”