Hospital has changed its procedures since death

A raft of new procedures relating to the care of people with learning difficulties have been introduced at a Norfolk hospital following the death of a patient with Down's syndrome.

Mark Shelton died at the Queen Elizabeth Hospital, King's Lynn, on August 14 last year after suffering apparently minor abdominal injuries in a car crash on the A149 near Wells.

The 37-year-old volunteer worker from Leicester had the mental age of a 10 to 12-year-old and would have struggled to communicate his symptoms, an inquest heard yesterday.

Mr Shelton, who had been on a family holiday, seemed to improve but had internal injuries which were not picked up by staff, the hearing was told. His father, Jeffrey, said the hospital should have involved the family more in his care because they knew him best.

Sarah Shelton, his sister, said she had to ask A&E staff to give her brother pain relief four times because he kept saying he was all right.

'I knew him better,' she said. 'He would not necessarily have cried out in pain. He was eager to please.'

Recording a narrative verdict, greater Norfolk coroner William Armstrong said that Mr Shelton had died from a previously undiagnosed peritonitis following his involvement in a road traffic collision on August 11. The hospital carried out a 'serious untoward incident report' following his death and Mr Armstrong praised the QEH for swiftly introducing the resulting recommendations.

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They included the appointment of a new learning disabilities liaison nurse – due to start work in the next few weeks – and extra staff training on the implications of learning disabilities on the diagnosis, monitoring and management of patients.

The report, written by consultant surgeon Nicholas Redwood, said Mr Shelton's condition had been carefully monitored, using measurements such as blood pressure and urine output. But an early warning score – calculated using those readings – was not acted on because he seemed so comfortable.

'The fact that Mark was sitting up, eating and chatting, may have been falsely reassuring,' he explained.

Mr Redwood said he also found the early warning forms confusing and they had since been rewritten.

'It's to the credit of the hospital that this matter has been taken seriously and lessons have been learned from this tragedy,' Mr Armstrong said.

Mr Shelton was first admitted to the QEH at around 7.40pm on August 11 following a head-on collision on the A149 Stiffkey Road at Warham that afternoon.

His father Jeffrey, who was driving, had inexplicably lost concentration and veered across the road before colliding with a Peugeot, the inquest heard. His son had been 'walking wounded' and showed some signs of shock. He suffered a blunt abdominal injury and had been vomiting, but he was alert.

Doctors performed a number of tests, including chest X-rays, but could find no evidence of serious internal injury.

In the early hours of August 14, he had suffered a cardiac arrest and could not be revived, the hearing was told.

Consultant surgeon Sujait Singh said 'everyone had been stunned' by his death.

Speaking after the inquest, Mr Shelton said he was pleased with the verdict and hoped the new measures would prevent a similar tragedy.