A mental health patient was failed in the care he received at Highbury Hospital, Nottingham which led to his death.

Steven Parkin was a 52-year-old man who lived in Nottingham with his wife. He had a diagnosis of Schizoaffective Disorder receiving care within his community, together with a noted medical history of ischemic heart disease, pre diabetes and frontal lobe atrophy. On 7th March 2022 following a recent mental health relapse he was placed under Section 2 detention (Mental Health Act) and admitted to Highbury Hospital within the Nottinghamshire Healthcare NHS Trust.

In the early hours on Friday 18th of March 2022 the nurse in charge raised the alarm as Steven was found to be in cardiac arrest, the nurse in charge then commenced CPR, an ambulance was called and paramedics attended. Further attempts were made at resuscitation, but at 4:21am Steven was transferred to the QMC Emergency Department. Efforts by the emergency team proved unsuccessful and at 5:18am he was declared deceased.

Missed Opportunities and Care Failings

On admission Steven was placed in a temporary bed on the Cassidy Suite. He was seen by several members of staff who noted his ‘hoarse voice’. A blood test, including CRP to pick up infection, was requested by a consultant however, this was not carried out as it was not allocated to a particular member of staff.

On the same day, physical health observations (National Early Warning Score – NEWS2) were logged noting low oxygen saturation levels which should have triggered more frequent hourly observations together with an alert of a medical emergency, requiring immediate doctor intervention, transfer to A&E for examination, treatment, and the administering of oxygen. This was not actioned.

Steven was transferred to a more permanent bed on Rowan 1 within Highbury Hospital within a few days. During initial Multi-Disciplinary Team meetings and within his 72 hour review Steven’s health conditions were not discussed or recorded. The logged NEWS2 scores evidence huge gaps of hours or days, where more regular observations should have been done.

On 15th March 2022 a decision was made to prescribe Steven with antipsychotic medication, Clozapine. Here, pre and post dose observations must be carried out twice daily. No such checks were carried out until the evening of 17th March.

On 16th March a junior doctor reviewed Steven after reports that he had red and swollen legs diagnosing a likely cause of heart failure. Rest was prescribed and the following day a decision made to prescribe medication, despite omitting to carry out physical health checks.

Steven was placed on visual observations of “not more than 10 minutes apart” on 17th March. Staff on duty failed to complete 17 of these observations. CCTV alarmingly showed staff using an iPad to log checks as complete (sometimes while on their mobile phones), despite being nowhere near Steven at the time.

Multiple members of staff falsified medical records by logging observations as being completed, with long periods where Steven, a vulnerable patient, was left alone unchecked with serious concern regarding monitoring or treating any breathing concerns in the hours before his cardiac arrest.

The Inquest hearing at HM Coroners’ Court Nottingham began on 5th March 2024 with evidence being heard over an 8 day period, before a jury.

The following conclusions were recorded:

  • The cause of death was pneumonia, with a background of heart failure.
  • Symptoms were not picked up by staff due to the dangerous practice of failing to observe patients and lack of knowledge of serious physical health concerns.
  • There should have been transfer to hospital for emergency treatment.
  • There were failings at every level, on every day following admission, due to lack of responsibility, lack of effective management, poor communication, and failure to complete basic physical and mental health observations according to policy and patient safety.
  • There were multiple missed opportunities, all of which would have probably prevented deterioration, allowed treatment and would have prevented death.
  • There were gross failings and failures to provide basic care to a very vulnerable and dependent person who could not provide such care for himself.
  • The death was avoidable and contributed to by neglect.

Steven Parkin’s wife Diane was represented at the hearing by Natalie Marrison of Ison Harrison Solicitors, who commented:

“The evidence that we have heard over the course of this Inquest tragically revealed serious and significant failings within the care at Highbury Hospital, Nottinghamshire Healthcare NHS Trust. There were numerous missed opportunities, inactions, and falsifications all of which led to this avoidable death.”

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