Lewis Victor Mendelson · Prevention of Future Deaths report

On 24th May 2019 I commenced an investigation into the death of Lewis Victor Mendelson. The investigation concluded on the 4th November 2019 and the conclusion was one of Narrative: Died from the recognised complications of cerebral palsy (the precise cause of which could not be established).

The medical cause of death was 1a) Aspiration pneumonia on a background of an episode of vomiting; 1b) Cerebral Palsy

Lewis Victor Mendelson had profound learning disabilities and physical disabilities. He was placed by the Local Authority in a community care facility. He was not subject to a DoLS. His last statutory 12 month review took place over 2 years before his death. He had no allocated Local Authority social worker. On the night of 8th May 2019 he vomited. He was taken to hospital some hours later. Repeated attempts were made to insert a nasogastric tube causing him significant distress. He was placed on end of life care with no formal best interests meeting or Independent Mental Capacity Advocate (IMCA) in place.

He returned to his home address with end of life care. He appeared to begin to improve and antibiotics were restarted. He subsequently deteriorated again and died on 16th May 2019 at his home address, 10 Firs Grove, Gatley.

1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death. He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages. There was no designated Social worker overseeing his care due to staffing shortages;

2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence that it would be beneficial;

3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.