KEVIN JOHN FITTON · Prevention of Future Deaths report

On 17th September 2019 I commenced an investigation into the death of KEVIN JOHN FITTON. The investigation concluded at the end of the inquest on 5th May 2021. The conclusion of the inquest was Drug related death/misadventure being myocardial infarction directly related to Spice use in circumstances where a failure to obtain an urgent echocardiogram on 12th July 2019 represented a missed opportunity to diagnose left ventricular hypertrophy and treat Mr Fitton in the High Dependency Unit. If the correct diagnosis had been made and if fluids had been administered in a more controlled way the outcome may have been different. The ongoing use of spice arose against a background of several years of ineffective care and support for stroke induced acquired brain injury causing self-neglect.

Kevin Fitton suffered a catastrophic stroke at the age of 33 in 2010. Prior to that he was a successful fit man enjoying his life in all respects. Following the stroke, although properly assessed by the leading neuropsychologist so that the damage was fully recognised, his ongoing care never reflected his needs. It was clear from the evidence that none of those providing that care understood the effects on him of his acquired brain injury. In particular during the nine plus years between the stroke and his death, Kevin’s mental capacity was only assessed on three occasions, the last being in 2013 at the insistence of one of his sisters. His last Care Act Assessment in 2017 was incomplete and not followed through. His care was branded ineffective by the Independent Safeguarding Adult Reviewer. The main problems were his self-neglect, his almost daily use, latterly, of Spice and his vulnerability which meant he was taken advantage of by some members of the street homeless community. His Spice use took him to Accident and Emergency on several occasions in the last two to three years of his life. The final admission was on 12th July 2019. Kevin required fluid support, however, the precarious state of his heart was not identified (a requested echocardiogram was not carried out). He became fluid overloaded, had a cardiac arrest and died some 27 hours after being brought into Hospital by ambulance.

(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately.
(2) There was a failure to seek specialist support regarding Acquired Brain Injury (ABI).
(3) There was a failure to understand the way Mr Fitton’s ABI impacted on his abilities.
(4) There was a failure to understand how ABI impacted on Mr Fitton’s substance use and vice versa.
(5) Communication between the various teams and individuals were poor.
(6) Lead and Co-ordination were lacking.
(7) There was a failure to react to the deterioration in Mr Fitton’s living conditions, his being cuckooed, the downward slide in his physical health and the increase in his drug use.
(8) Staff received no adequate training in dealing with ABI. There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act.
(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented. It should have been repeated annually – it was not.
(10) There was a failure to deal with Mr Fitton’s situation robustly.