Death of man in bath raises concerns other patients are at risk
PUBLISHED: 09:10 22 April 2020 | UPDATED: 18:41 22 April 2020
Patients disengaging with health services are being put at risk by a lack of follow-up support, a coroner has warned after a 31-year-old man drowned in his bath following an epileptic seizure.
Darren King was found unresponsive in the bath of his Lowestoft home on April 8, 2017, with an inquest concluding, on February 24 2020, his death was an accident.
Mr King’s last contact with his care co-ordinator from Norfolk and Suffolk NHS Foundation Trust (NSFT) was in June 2016, and he last saw his GP in September of the same year, with Suffolk’s senior coroner Nigel Parsley noting the lack of contact offered no opportunity to review his epilepsy treatment regime or monitor his seizure history.
In the report, sent to Suffolk County Council’s Adult and Community services and NSFT, Mr Parsley states: “In my opinion, there is a risk that future deaths could occur unless action is taken.
“In this case, it was clear that due to his learning disability and autism, engagement with him could be difficult. However, the following three areas of concern were identified.
“The lack of effective follow-up action when a patient with learning disabilities disengages, especially when they are a high-risk patient, such as Darren.
“The lack of a clear escalation process when an increased risk is identified and this risk cannot be easily addressed.
“The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral and escalation routes should they have a concern.”
A spokesperson for NSFT confirmed they have received the report and are in the process of preparing their response, which is scheduled for June 2020.
A spokesperson for Suffolk County Council said: “We are currently considering the report received from the Coroner’s office and will be responding, as requested, with the actions being taken in light of this tragic incident.”
The inquest heard that fraudulent psychiatrist Zholia Alemi was “one of a number” to treat Mr King when she worked for NSFT between April 2014 and April 2015, although Mr Parsley found she did not contribute to Mr King’s death.
At the time of his death, Mr King was under the care of Suffolk County Council’s Adult and Community Services, the NSFT, and his local GP.
In the report, Mr Parsley states: “It was documented that the agencies involved in his care were aware of the significant risk bathing posed to Darren due to his epilepsy.
“In September 2016, Darren saw his GP. At this time he was having seizures up to three times a week. His epilepsy medication was increased and he was told he needed a further review in three weeks time.
“This was the last reported contact with a medical or mental health professional regarding his treatment plan and, although seen by support workers from other agencies, there was no further contact made with him by medical or mental health professionals in the six months leading up to his death.
“On the balance of probabilities, had opportunities to provide adequate monitoring and treatment relating to Darren’s epilepsy been taken, then his death may have been prevented.”