Several opportunities were missed in the case of a Lowestoft man with down's syndrome who died at Ipswich Hospital in 2012, a safeguarding chief at the region's mental health trust told an inquest.
Saranna Burgess, named nurse for safeguarding and adults at the Norfolk and Suffolk NHS Foundation Trust (NSFT), gave evidence at an inquest into the death of Richard Handley at Suffolk Coroner's Court in Ipswich today.
The inquest heard Mr Handley had suffered from lifelong constipation problems and mental health issues, which included psychosis.
Senior Suffolk coroner Dr Peter Dean told the court one of the trust's former consultant psychiatrists Dr Salman Ahmad – who saw Mr Handley on a regular basis – was told about concerns regarding his distended stomach by carers, leading him to refer the 33-year-old for an urgent GP appointment. Dr Dean said Mr Handley's condition and behaviour appeared to decline in the year before his death at Ipswich Hospital's A&E on November 17, 2012, from complications of a bowel obstruction.
He added: 'Richard was outgoing, chatty, active and friendly. He enjoyed swimming and playing board games.
'The level of social interaction over the proceeding 12 months up to his death was noted to be in decline by all of those involved.'
Giving evidence, Ms Burgess – who carried out an individual management review (IMR) for NSFT after Mr Handley's death – said there were missed opportunities to discuss his case within the multi-disclipinary Community Learning Disability Team.
She told the hearing: 'I think there were several missed opportunities – the change in Richard's accommodation, the change in Richard's behaviour.
'These were occasions when the psychiatrist could have discussed the case of Richard within the multi-disciplinary team.'
In the IMR, which Dr Dean read to the court, Ms Burgess added it would have been reasonable to expect Dr Ahmad, a specialist in learning disabilities, to physically examine Mr Handley given the level of concern about his appearance.
She said that had the psychiatrist discussed the case and considered the potential link between physical and behavioural symptoms, Mr Handley may have been admitted to hospital earlier.
The inquest continues tomorrow.
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