Family of Coppull man frustrated as inquest reveals delays and human error in lead up to his death - but coroner rules it "impossible to tell" if they contributed to his death

The daughters of Terence Joseph Wilson are convinced that delays in his care after leaving hospital contributed to his death - and were even told by the family GP that he considered it "professional negligence".

Such were the GP's concerns, that an inquest to investigate the weeks leading up to the 69-year-old's death was held at Preston Coroner's Court on Thursday.

In court, Mr Wilson's family said he had only been out of bed once in the 85 days before his death and evidence of several delays and human error were revealed - including delays in referring Mr Wilson to a dietician, incorrect physiotherapy records, delays in the occupational therapy system and case notes being mislaid.

One of Mr Wilson's daughters, who was not identified in court, said: "We're not naive - we know we would have lost him further down the line - but I do believe we've lost our father a lot quicker than we should have.

"We believe the failings have brought his death sooner."

But after hearing the evidence of 11 other witnesses, GP Dr Michael McParlin of Coppull Medical Practice stepped back from his position and claimed there was no evidence of professional negligence.

When questioned about his stance by coroner Richard Taylor, Dr McParlin said: “I don’t recall saying professional neglect."

Mr Taylor interjected saying: "But that's really why we're here".

To which Dr McParlin said: “We sometimes use words we sometimes regret. But I think I was wound up by the lack of professional care.”

He elaborated that he wished to have seen more physiotherapy for Mr Wilson and said he was "surprised by the sheer number of agencies involved, working independently and maybe not terribly well together."

Coroner Richard Taylor said it was "impossible to say” if delays had contributed Mr Wilson’s death.

What happened?

The court heard that Mr Wilson, who was described as being frail, with vascular dementia, type 2 diabetes and a history of bowel cancer, stokes and high blood pressure, died in Chorley Hospital on September 24, 2021 from aspiration pneumonia with contributory factors being chronic kidney disease, vascular dementia and frailty.

The grandad-of-four had been on the radar of Lancashire County Council's social care team since May 2021, when the North West Ambulance Service made a referral due to his wife Audrey reporting she was struggling to deal with some of his behaviour.

Mrs Wilson was offered residential, day care and domicillary respite, but declined, saying she felt she could cope with her husband's condition. A safeguarding referral was also declined.

Falls

In early June 2021, Mr Wilson was admitted to hospital after suffering a fall. When he was discharged to his home in Burwell Avenue days later, he was assessed as being able to ascend and descend stairs and moving at his pre-admission level.

He then suffered another fall on June 28, 2021 and on July 1, crisis care was put into place, which would be kept up until a care package could be sourced.

A package was agreed almost a month later with Jewel Home Support for two carers to attend three times a day, carrying out toileting, turning and personal care.

An occupational therapist instructed carers - both crisis and from Jewel - to transfer Mr Wilson from his bed to a nearby chair, but they reported that he wasn't weight-baring and couldn't be moved.

By August 3 the family were expressing concerns that Mr Wilson was developing pressure sores and struggling to swallow and eat.

District nurses

Jennifer Joyson, a district nurse who covered the Coppull area at the time in question, said that her team had been involved in Mr Wilson's care since March 2020 due to concerns over his skin, and carried out three monthly visits.

On August 5, 2021, she said a nurse attending to check sores on his sacral area (bottom of the spine) was unable to do so because of Mr Wilson's immobility.

The nurse - who was not named in the inquest - claimed she had made a referral to the rapid referral team for an occupational therapist assessment, but Ms Joyson said there was "no physical evidence to show that".

She also did not arrange for two nurses to go back and carry out the check, failed to book a review onto the electronic booking system, and she took Mr Wilson's case notes away from the house, but then went on long-term sick, so a new nurse attending on August 14 did not have the relevant information.

Domicillary care

Jewel Home Support began care of Mr Wilson on August 4, but there was a delay in the care starting due to paperwork issues.

Jade Wallis, care manager for Jewel said that LCC had initially only sent a postcode, the sex of the patient and times of the visit. This was disputed by a lawyer for LCC.

Ms Wallis also said that Mr Wilson had been reluctant at first to receive personal care.

Mr Wilson's family interjected that "it was carers who were reluctant to clean him" and claimed that "they were there for two minutes of a half hour call and that happened quite frequently".

Ms Wallis didn't directly address the concerns, but said that there was an electronic monitoring system in place - as well as paper records - to check how long a carer had been at a property.

A safeguarding complaint made by the family against the carers on August 20 was found to be unsubstantiated when investigated.

Occupational therapy

Occupational therapist Gemma Parkinson became aware of Mr Wilson after he was listed by the crisis team on July 23, and she picked up his case on August 6.

She said that there are only four occupational therapists covering the whole of Lancashire and that it was a "normal" amount of time to pick a case up and "it can be a lot longer".

After phone and in-person assessments, a specialised supportive chair, hoist and moving and handling equipment were ordered on August 13 and were all in place within a week.

She told the court that although the equipment was in place, Mr Wilson could not be moved downstairs to interact with his family until a district nurse had arranged for patient transfer – something that happened on August 24, 2021.

Ms Parkinson also at that time asked for a referral to physiotherapy and chased that up five days later, only to be told that the records showed old information that he was mobile, able to stand and transfer.

She told the court that it is typical for a 14 to 18 week wait to see a physiotherapist.

Speech and Language Therapy (SALT)

Elizabeth Lemon, a team leader for speech therapy at Lancashire Care assessed Mr Wilson in August 2021 for reported swallowing difficuties.

She said she believed the reason Mr Wilson wasn't eating was because of behavioural changes - possibly due to his dementia - and that he "had a functioning swallow".

Because Mr Wilson was only eating small amounts, she asked the GP to refer Mr Wilson to a dietician.

The GP took nine days to make a referral, which was eventually declined on Septmber 3.

Investigation and changes

Thomas Cole, patient safety lead for Lancashire said a review of Mr Wilson's care had been undertaken and that failings had taken place.

He said: "I agree, the joined-up approach could be improved".

He said a report identified problems with documentation and that notes being removed from the house "wasn't good enough".

He also said that there was "a lack of recognition of mental capacity" and that having separate electronic and paper notes "makes errors easier to happen".

Catherine Woods from Lancashrie and South Cumbria Foundation Trust said that the Trust was in the process of implementing an electronic record system that could be easily accessed by a number of health professionals and that an icon would be added to a file if it had been taken from the patient's home.

The Trust is now also changing the policy to allow professionals to make direct referrals to people such as dieticians without having to route this through a GP.

Conclusion

Mr Taylor concluded that Mr Wilson had died from natural causes, which were aspirational pnuemonia with contributory factors being chronic kidney disease, vascular dementia and frailty.

He recorded a narrarive verdict.

He said: "It is impossible to say if delays contributed to his death.

"My own belief from the evidence I've heard is that the sooner he is moved and gets out into a chair, the better.

"However, thats a 'what if'?"

The family

Speaking after the inquest, Mr Wilson's three daughters said they had been left "very frustrated".

They said: "We had to fight for his care for the 13 weeks after his fall. What about all the other people who don't have people to fight for them?

"We do believe that the time taken to do anything contributed to his death."