Steven Jones · Prevention of Future Deaths report

On 03/03/2016 I commenced an investigation into the death of Steven Jones, 27. The investigation concluded at the end of the inquest on 14 November 2017. The conclusion of the inquest was a narrative conclusion of:
natural causes in circumstances where it is unclear whether any deficiencies in care and or delays in seeking further medical advice contributed to his death.

Steven Jones, a young man aged 27 years at the date of his death had serious learning difficulties, was in the autism spectrum and was non-verbal. He was a resident at Beech Cliffe Grange Care Home, Rotherham where he was generally well cared for. He became ill on the 21st November 2013 with symptoms of sickness and diarrhoea, loss of appetite and sleeping disorder, some of which were manifest at various times until his death on 10th December 2013. One of the registered managers consulted his general practitioner on 28th November 2013 in his absence. Handovers sheets were reasonably well completed by carers between 21st November 2013 and 8th December 2013 but concerns were not always emphasised, incident reports were never raised, and the quality and nature of verbal communication to senior staff and managers was not clear. Despite a brief period of improvement after 28th November 2013 his condition deteriorated and he vomited faecal matter on the 8th December 2013. He was admitted to Rotherham General Hospital on that day where a CT scan confirmed by surgery on the 9th December resulted in a diagnosis of a perforated colon leading to multi-organ failure and his ultimate demise. He died on the 10th December 2013 and an Assistant Coroner accepted the medical cause of death as follows:
1a. multi-organ failure and hypoxic brain injury
1b. cardiac arrest
1c. spontaneous perforation of sigmoid colon (operated)
2. severe autism

before issuing the appropriate documentation. Anonymous letters raised several matters and after they were referred to the Coroner by the police an investigation was opened on the 3rd March 2016.

(1) Although a system of written recording was in place, concerns of carers were not emphasised nor escalated to seniors either through incident reports or verbally so that opportunities to initiate full investigations by seniors and/or managers were lost.
(2) Staff did not appreciate the importance of incident reports and that such reports encompassed illness.
(3) In practice staff did not act directly in dealing with illness of a resident, rather channelling medical issues through the registered managers.
(4) On the occasion of a serious incident of faecal vomit, staff did not assume responsibility for calling emergency services but telephoned the registered managers who in turn did not appreciate the seriousness of the situation resulting in a delay in transferring the resident to hospital.
(5) In the case of a non-verbal resident with serious problems very early referral to a general practitioner was not made and when made the resident was not present at the consultation nor was his one to one carer in attendance.