Family respond to today’s Serious Case Review following death of their son

Richard Handley died from complications arising from faecal impaction, aged 33

The release today of a Serious Case Review by Suffolk Safeguarding Adults Board has been welcomed by the family of one of the people whose death led to the review.

The report looked into the circumstances of Richard Handley’s care and death, and refers to Richard under the fictitious name of James.

Richard died on 17 November 2012 at Ipswich Hospital. He had Downs Syndrome and developed mental health issues at around age 18. Part of his care required the careful monitoring of his diet and bowel movements because Richard had a lifelong condition of chronic constipation. He moved into residential care home, Bond Meadows, in Lowestoft, Suffolk in 1999 and had a well-monitored care and diet plan. In 2010, the care home was de-registered from residential care to supported living.

During the months before his death, Richard’s mental health was recorded as deteriorating and he received increased psychiatrist input from the Norfolk & Suffolk NHS Foundation Trust. At the last visit on 12 November, the psychiatrist noticed that Richard’s abdomen was distended and hard. He asked staff at Bond Meadows to call Richard’s GP urgently; the GP examined him the next day and prescribed extra laxatives. On 14 November a place became available at the Mental Health Assessment and Treatment Unit, Ipswich but on arrival Richard was referred by the admitting staff to Ipswich Hospital due to concerns about his massive abdominal distension. Richard had an x-ray that showed colonic distension with faeces affecting the whole colon. Constipation must be carefully monitored as it can be a sign of or can result in deteriorating mental health, in addition to posing obvious physical risk.

At around midday on 15 November, Richard was examined under anaesthetic and the surgeon removed 7-10kgs of faeces. Post-surgery, Richard’s condition did not greatly improve, his abdomen remained distended and he continued to vomit. His vital signs deteriorated. Richard had an x-ray an hour before his death that was consistent with a large bowel obstruction and that it was likely he would vomit. During the early hours of 17 November, Richard had a cardiac arrest and died. At post mortem it was found that the bronchi and nasal passages contained gastric contents and that it was likely that death was through aspiration. Cause of death was recorded as 1a aspiration of gastric contents, b. large bowel obstruction, c. faecal impaction.

Now that the Adult Safeguarding Review has been published, Senior Coroner for Suffolk, Mr Peter Dean, will determine when an inquest will be held.

Julie Say, is a clinical negligence partner at Hodge Jones & Allen, and is representing the Handley family, she says: “The family were very shocked by Richard’s sudden and unexpected death. Richard was a much loved member of the family and is greatly missed. The family are relieved that the report is, after such a long time, finally complete. Many failings have been identified and we now hope that the forthcoming Coroner’s inquiry into the circumstances of Richard’s death will improve the standard of care people with learning disabilities receive in Suffolk and beyond, and prevent events such as these ever happening again.

“The Handley family are deeply saddened by the treatment that Richard received by all the service providers involved in his care. They struggle to understand why such a well-known problem was not being monitored as it must have caused their son much distress and ultimately led to his death.”

Suffolk Adult Safeguarding instigated a multi-disciplinary report contributed to by Bonds Meadow (United Response), Suffolk County Council (Social Services), Norfolk & Suffolk NHS Foundation Trust, Ipswich Hospital NHS Trust, Bridge Road Surgery (GP) and Suffolk Constabulary.

The report can be viewed here.