Shane Luke West · Prevention of Future Deaths report

On the 20th August 2018 I commenced an investigation into the death of Shane Luke West. The investigation concluded at the end of the inquest on the 19th July 2023.

The medical cause of death is
1a) multi organ failure
1b) cardio respiratory arrest
1c) abdominal distention caused by faecal impaction
2) Sotos syndrome, scoliosis

The conclusion of the inquest as to how Mr West came to his death was a narrative conclusion and is as follows:-

The deceased died from multi organ failure caused by cardio respiratory arrest due to increased pressure on the lungs from abdominal distention. The distension was caused by longstanding chronic constipation and fluid build up from his laxative treatment.

The deceased was Shane Luke West and he was pronounced dead on the 17th August 2018 at Morriston Hospital, Swansea. The cause of death was multi organ failure caused by cardio respiratory arrest due to increased pressure on the lungs from abdominal distention, which itself was caused by longstanding chronic constipation and fluid build up from his laxative treatment.

Shane was admitted to Morriston Hospital on the 31st of July 2018 with chronic constipation and abdominal swelling. The treatment plan was conservative consisting of laxatives, enemas and colonic irrigation. Shane also had SOTOS syndrome and suffered from a learning disability. The learning disabilities team of the Health Board were involved to allow Shane to understand the treatment being offered. It was noted that the extent of the constipation on admission was causing significant abdominal distention the result of which meant that Shane's abdomen was pushing his diaphragm up into the chest cavity thereby restricting his lung function. Shane underwent regular examinations with varying results. On some occasions his abdomen felt distended, and on others it felt soft and non tender, suggesting improvement. On the 16th of August 2018 Shane deteriorated with respiratory compromise. Shane underwent a colectomy and ileostomy formation to decompress the abdomen to allow effective mechanical ventilation. Whilst this procedure provided temporary improvement, Shane eventually declined further and passed away on the 17th of August 2018.

I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives.

1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018.
2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition.
3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function.
4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid