TERENCE TALBOT · Prevention of Future Deaths report

On 29th October 2020 an investigation was commenced into the death of TERENCE TALBOT. The investigation concluded at the end of the inquest on 19th October 2021. The conclusion of the inquest was 1a Multiorgan Failure 1b Empyema and Pneumonia 1c DRESS Syndrome Narrative Terence Talbot died from a complication of necessary medical treatment with prescription medication for his deteriorating mental health to which he suffered a very rare and severe allergic reaction with a poor prognosis. The absence of regular dermatology review, lack of application of emollients for whole body severe exfoliative dermatitis and food and fluid not being adequate to meet his needs leading to malnutrition amounted to a gross failure to provide basic medical care that would have prolonged but probably would not have saved his life.

Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9th April 2020 of Multiorgan Failure due to Empyema and Pneumonia caused by DRESS Syndrome diagnosed on 31st October 2019 as a consequence of a severe reaction to therapeutic prescription of Olanzapine and Risperidone medication to treat Bipolar Affective Disorder in September and October 2019 whilst he was detained under the Mental Health Act. Terence had multiple discharges from acute hospital following admission for symptoms of DRESS syndrome with severe exfoliative dermatitis. Prescribed emollients were recorded as self-administered although Mr Talbot could not apply them effectively himself. Food, fluid and nutrition was not adequate to meet Mr. Talbot’s needs and nasogastric feeding was commenced on 26th February 2020 after escalation from the Discharge Liaison Nurse and a best interest meeting. Mr Talbot’s sister persuaded him to co-operate although this feeding did not meet his needs. Mr Talbot was cachexic with deranged electrolytes and suffered malnutrition. He was treated for aspiration pneumonia on 3rd March and suffered a left sided pneumothorax on 4th March treated with drain insertion. Mr Talbot was diagnosed with empyema treated with antibiotics and his DRESS Syndrome failed to improve and he was placed on end-of-life care.

Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.

(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.

(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.

(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.