Russell James Felstead · Prevention of Future Deaths report

On the 7th February 2013 I commenced an investigation into the death of Russell James Felstead date of birth 04.12.1959. The investigation concluded at the end of the inquest on 07.01.2014. The conclusion of the inquest having heard the evidence was an open conclusion.

Mr Felstead had severe learning disabilities. He was unable to talk and communicate and required a high level of support and care. He lived in a purpose built home with three other residents and Choice Support provided the supported living needs of the residents. Mr Felstead required the highest degree of care and support. In addition to his learning difficulties he had a diagnosis of epilepsy for which he was prescribed medication. He was not known to have had a seizure for approximately four years. As part of his disabilities Mr Felstead was unsteady and was prone to falls, in addition if sat on the floor he was regularly known to throw himself on the ground. In order to try and prevent injury to his head, a helmet had been purchased which he wore all the time except when bathing.

On the 7th January 2013 Mr Felstead was found in his room on the floor, unresponsive. The carer on duty telephoned an ambulance. The information passed to the Ambulance Service and subsequently on to the Emergency Department of Stepping Hill Hospital was that Mr Felstead had had a seizure. In evidence the carer indicated that this is what he had thought had happened. However the evidence from the Ambulance Service was that it was clearly indicated to them by the carer that a seizure had actually occurred.

Mr Felstead was taken to Stepping Hill Hospital; no-one attended the hospital with him.
In addition, specific medical documents which should have gone with Mr Felstead in the event of any hospital admission were not handed over. This document provided information as to his general medical condition and demeanour.

Later in the day on the 7th January another Carer attended the hospital and took Mr Felstead’s helmet and provided further information to the hospital as to his general behaviour and difficulties. By 19.50 it was recorded in the Nursing notes that Mr Felstead was prone to falls and that he wore a helmet.

It was not until the 11th January that this information was noted by the doctors at which stage an urgent CT scan was requested which showed the presence of a subdural haematoma. The deceased was transferred to Salford Royal Hospital where he was operated on. He died on the 28th January 2013.

Doctors must ensure that all relevant information is accessed and read even if this is in the Nursing notes as opposed to the Clinical records. It is clear that the information which prompted an urgent CT scan on the 11th January had been available in Mr Felstead’s medical records since the 7th January and his helmet had in fact been at the hospital.