Derek LEE · Prevention of Future Deaths report

On 5th June 2016 I commenced an investigation into the death of Derek LEE. The investigation concluded at the end of the inquest on the 6th February 2017. The conclusion of the inquest was NATURAL CAUSES.

See Record of Inquest

(1) Mr Lee’s medication regimen which was to be the core of the admission was barely addressed and no reasons for any changes in medication appear in his notes.

(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete.

(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that.

(4) No Waterloo score was done until the 4th May. Too late. No appropriate pressure relieving equipment was ordered until the 12th May. There was no evidence before me that the equipment was ever received or used for Mr Lee. When Mr Lee was admitted to the Acute Hospital he had a Grade 2 pressure sore on his Sacrum.

(5) The thromboprophylaxis assessment which should have been carried out on either the 27th or 28th April was not done until the 6th May.

(6) No bowel chart was kept until the 12th May. Why Why not? Even non nursing, non-medical professionals know that one of the several dangers of Parkinson’s Disease is constipation.

(7) Medical instructions and recommendations were not handed over. One example relates to instructions to clean Mr Lee’s infected eyes with saline every two hours to keep them open. This was not done and when he arrived at the Acute Hospital his eyes were crusted shut.

(8) The MUST score was properly calculated on admission but not reviewed when it was clear he was not eating.
There was no evidence of any reaction to Mr Lee’s substantial weight loss.
There was no referral to dieticians. They just happened to attend a multi-disciplinary meeting on the 9th May (he was admitted on the 27th April and by the 9th May had lost 10 and ¾ pounds – 4.80 kilos). Re-weighing was requested by the dieticians. It did not take place.

(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days. It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late.

(10) There was apparently no appreciation of the deterioration in Mr Lee’s mobility. He was at high risk of falls and yet the mobilisation of a Parkinson’s patient is imperative and also since he was being specialised during his entire admission there is absolutely no excuse for not trying to assist him with mobilising.

(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.

(12) As time went on there was no regular review of his original Assessments. This should have been done apparently by his Primary Nurse who carried out none of these functions and therefore her appointment for Mr Lee was irrelevant.
There should be a review of the role of Primary Nurse.

(13) There was no coherent and carefully considered and reviewed Care Plan.

(14) A Care Co-ordinator was not appointed, even though at the Inquest, it was confirmed that Mr Lee was being looked after on the Care Programme Approach (CPA).
The appointment of a Care Co-ordinator is at the heart of this framework and it was clear that such an appointment could have been helpful if not crucial in Mr Lee’s case.

Brunswick is supposed to be a specialist unit for patients with Mr Lee’s problems and yet it is clear that he was failed most miserably. It is equally clear that these specific failings, even in combination and on the balance of probabilities did not change the outcome (ie. Mr Lee’s death) on the 5th June 2016, however they were all matters that need addressing in order to raise the standard to an appropriate level for the proper care of these vulnerable patients.