Dennis Bennett · Prevention of Future Deaths report

On the 5th April I concluded the Inquest into the death of Dennis Bennett date of birth 24.07.1939 who died on the 07.02.2016. The cause of death was (a) Dementia

I recorded a natural causes conclusion.

The Court heard evidence that the deceased had a history of dementia and on the 29th November 2015 was admitted in accordance with Section 2 Mental Health Act to the Moorside Unit under the care of Greater Manchester West Mental Health Trust. (GMW).

The deceased was shortly after his admission transferred to Wythenshawe hospital for medical treatment before being returned to the Moorside Unit on the 6th January 2016. At this time he was admitted under Section 3 of the Mental Health Act for ongoing treatment for his mental health.

The treatment plan was initially for him to be well enough to be discharged to nursing home care. However on the day of the nursing home assessment his condition deteriorated and he was no longer well enough to be discharged. By the 13th January he was for end stage palliative care and following a meeting with the family the plan was that he would remain on ward in the Moorside unit.

On the 14th January the Consultant made an urgent Deprivation of Liberty Safeguarding Application to Trafford Council. As this was an urgent application the application commenced on the 14th January. At this time the deceased was in fact still being detained under S3 of the Mental Act and this was not rescinded until the 15th January 2016.

The urgent application expired on the 21st January 2016 at which time GMW contacted Trafford Council as the standard authorisation had not been considered. It was the understanding of GMW (albeit the witness from GMW who had responsibility for safeguarding in the Trust was in fact employed by Trafford Council) that the urgent application continued until the best interest assessments could take place and the deceased despite now being on end stage palliative care was subject to DOLS at the time he died.

Another employee of Trafford Council provided evidence that when he was asked for advice from the Trust the position of the Council was that there was no DOLS in place following the expiration of the urgent authorisation until such time as the standard application had been processed.

1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.

Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.