Doreen Elma STAPLETON · Prevention of Future Deaths report

On 29 September 2016, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Doreen Elma Stapleton, aged 78 years. The investigation concluded at the end of the inquest on yesterday. I made a narrative determination at inquest, which I attach to this letter.

Doreen Stapleton died on 15 September 2016 at the Whittington Hospital from a pulmonary thromboembolism.

Doreen Stapleton had been admitted to the Whittington Hospital previously and diagnosed with pulmonary emboli. Upon discharge, ten days before her death, a plan was made for district nurses to attend her home daily, to administer tinzaparin injections. However, the referral was never received by the district nursing team, because an obsolete email address that had not been deleted from the computer system was used.

I am satisfied that Whittington Health has already taken steps to deal with the cause of the failure of the district nursing team to attend – the obsolete email address. I write in respect of an ancillary, but nevertheless important matter, that of the instructions given to Ms Stapleton and her family upon discharge.

During her six day admission, Ms Stapleton was told explicitly by one of her treating consultants that without medication she could die, and she did understand this. She was then persuaded to remain in hospital for treatment. However, she later decided that perhaps she wanted to leave after all, so on the afternoon of Friday, 2 September 2016, she was detained under section 5(2) of the Mental Health Act.

By Monday morning, she was deemed fit for removal of the section, and fit for discharge. It well may have been that her confusion on the Friday had been a consequence more of her low oxygen saturations at that time, than of her schizophrenia. Nevertheless, she was a vulnerable patient.

When she was discharged, although the plan of daily district nursing visits was made clear to her, no member of the team had another very explicit conversation with her or with her two sons, about the potential consequence (i.e. death) of the visits and medication administration not taking place. She and her sons were not given the telephone number of the district nursing team and were not told to ring if nurses failed to attend the following day. I understand that patients are now all given a leaflet with the district nursing team telephone number, but I am concerned that there is still a lack of emphasis on this aspect of discharge advice.

I heard from one witness that this is a whole team responsibility. Any member of the team – consultant physician, consultant psychiatrist, discharge nurse – could have had this very direct conversation with Ms Stapleton and her family, but nobody did. I appreciate that there may be a reluctance to be so blunt because of a fear of scaring patients, but any reluctance must be overcome in certain situations if patients are to be supported in the best way possible. Indeed, it had already been overcome by one consultant earlier in Ms Stapleton’s admission.