Darren Jones · Prevention of Future Deaths report

On 29th October 2021 I commenced an investigation into the death of Darren Jones. The investigation concluded on the 6th June 2022 and the conclusion was one of Narrative: Died from the complications of necessary catheterisation. The medical cause of death was 1a) Sepsis; 1b) Urinary Tract Infection on a background of long term catheterisation; ii) Chronic bladder outflow obstruction, Chronic Kidney Disease

Darren Jones had severe learning disabilities and lacked capacity. He had a long term catheter fitted after developing urinary retention. He had chronic kidney disease as a consequence of his history of urinary retention. He was admitted to Stepping Hill Hospital following three unsuccessful attempts to change his catheter in the community. Further attempts in the Emergency Department were unsuccessful and he was admitted to Stepping Hill Hospital. At 10:04 on 21st October 2021 he had a NEWS2 score of 8. At 11:38 he was placed on the sepsis pathway on patient track and intravenous antibiotics given. He deteriorated throughout the day despite treatment. On 22nd October 2021 he died at Stepping Hill Hospital from sepsis.

1. The Inquest heard that delivering care in the community to Mr Jones in relation to his catheter care was impacted by the significant demands on the District Nursing Team due to their staffing levels against their caseload. The evidence was that the District Nursing Teams were under significant pressure which impacted the support and care they could deliver;

2. Mr Jones had significant learning difficulties which were not fully recognised at the hospital to ensure that he was provided with support and that an IMCA was put in place to ensure his best interests were met. The Inquest heard evidence that it was important that all clinicians and health care professionals were clear and understood how to effectively support someone with a learning disability to ensure they were given the best and most appropriate care;

3. The Inquest heard that there was a dispute between two Local Authorities regarding training in catheter care. This impacted the provision of respite care and his health and wellbeing;

4. No LeDeR appeared to have been commissioned on the evidence before the Inquest.