Tranquilisation changes came too little too late for Norwich man, says sister
PUBLISHED: 18:36 04 February 2018 | UPDATED: 08:19 05 February 2018
The sister of a mentally ill man who died after being tranquillised in hospital has slammed the region's mental health trust for not addressing problems with the practice sooner.
Neil Jewell was just 42 when he died in January 2014.
And a inquest into his death found failings in the care he received from Norfolk and Suffolk Foundation Trust (NSFT) - including how he was observed after being tranquillised.
On January 25 this year NSFT committed to improving the checks on patients as it was revealed they could only be sure checks had been carried out 18pc of the time - but for Mr Jewell’s sister Christine Welfare, the changes came too late.
Mr Jewell died on January 17, 2014 - 11 days after he initially arrived at Norwich’s Hellesdon Hospital, having run out of Clozapine, his schizophrenia treatment drug.
NSFT placed him in Hamilton House care home in Catfield - which was rated inadequate and has since closed down - as they did not have enough beds for him.
But when his condition deteriorated, he was taken to West Suffolk Hospital and then on to Ipswich Hospital, laid face down on an ambulance stretcher with his arms and legs restrained.
He was placed in a seclusion room at Ipswich Hospital’s Woodlands Unit under apparent constant observation.
However it later transpired he had only been watched via CCTV, and although he had been seen lying face down no one had checked on him in person.
The next day, January 12, he was found unresponsive after suffering a cardiac arrest. He never regained consciousness.
Mrs Welfare, who lives in Aylsham with husband Edward, said: “At the time we were reassured that these things had already been looked at, Jane Sayer (the trust’s former director of nursing, quality and patient safety) said staff at Ipswich Hospital knew it was a poor standard of nursing.
“Obviously Dawn Collins (the interim director) has been tasked with addressing these ongoing issues which Jane Sayer stated had already been reviewed a year ago following Neil’s inquest. This was a very serious area brought under scrutiny by the jury and coroner. It is not acceptable to turn this in to a paper exercise of form filling.
“If these basic physiological checks are not made at very crucial times following rapid tranquilisation, then people will continue to die unnecessarily.”
Mrs Welfare also met with former chief executive Michael Scott, who told her policies had been put in place. And statements from the trust at the time said improvements had been made.
But in the trust’s latest inspection report, released in October last year, the Care Quality Commission found rapid tranquilisation was being used too often and physical checks required after tranquilisation had not been done.
And at the trust’s board of director’s meeting on January 25 it was revealed proof patients had been checked often enough were filled out just 18pc of the time.
Service user governor and GP Dr Richard Gorrod said it was “appalling” and medical director Dr Dohdan Solmka was tasked with bringing the rate up to 95pc by the end of March next year.
Dr Solomka said: “Our trust and our board are not satisfied with the current standard of practice around the monitoring of rapid tranquilisation and we have put in place immediate measures to ensure safer practices.
“This matter was put on our trust’s risk register in the autumn following our own internal review. This review showed us that the full and proper recording of regular monitoring and observations is lacking.
“So, even when patients have been kept safe and monitored properly, the patient record does not offer us full assurance us that safe practices were followed. We therefore cannot assume that the highest standards have been followed every time.
“We are looking at the paperwork on a case by case basis to identify where this recording is not being noted properly and to discuss this with teams.
“In addition to this, more senior staff members have been asked to supervise the application of rapid tranquilisation and we are reviewing all staff who might administer this treatment to ensure their understanding of safe practice and safety standards is sufficient.”