The head of a health trust has apologised to the family of a Newmarket man who died in hospital because staff did not know resuscitation procedures.
Twenty-nine-year-old stud hand Elliot Young, of Windsor Road, who had a history of mental health problems, choked after inhaling his own vomit on the Northgate ward at West Suffolk Hospital in Bury St Edmunds where he was a voluntary patient.
After an inquest on Wednesday, Michael Scott, chief executive of the Norfolk and Suffolk NHS Foundation Trust said:” I wish to offer my sincere and profound apologies for the failures in the care provided to Elliot shortly before his death. The trust has reviewed its practices as a result of Elliot’s death and has introduced more robust CPR and resuscitation training as well as policies for observing and caring for service users who are intoxicated. Although we do not know whether or not Elliot’s death could have been prevented, we hope and believe that these changes will avoid similar problems occurring in the future.”
Greater Suffolk Coroner Dr Peter Dean, said there had been “significant failures” in the care Mr Young had received in September 2012 when he had returned to the ward after a bout of heavy drinking. He had been taken to his room, where staff had placed him on his side in the recovery position on the floor next to his bed. But no checks, were made as staff taking over the night shift were not told to do any.
When staff went into Mr Young’s room at 11.20pm on September 4, they found he had stopped breathing, his pupils were dilated and he had alcohol coming out of his nose. But they didn’t know how to use a nearby defibrillator. They also failed to call the crash team because they feared the alarm would wake other patients.
“All the patients were asleep at the time. We had a very difficult evening with a lot of patients causing angst and stress,” staff nurse Matt Revans told the inquest.
Two years on the inquest heard that staff were still unclear how and when to perform these observations with one staff nurse unaware of new policies linked to the care of intoxicated patients introduced as a result of Mr Young’s death.
Dr Dean said: “I am still worried and deeply concerned about the lack of understanding of the duty to monitor levels of consciousness and the mechanisms of monitoring someone at serious risk and I was not persuaded that the care provided was adequate.
“Given he did appear in what was a very intoxicated state, it is very difficult to see why that did not trigger, in health care professionals, a far more robust response in terms of understanding the need to provide appropriate monitoring of a potentially life-threatening situation and that was a significant failure.”
A post mortem revealed Mr Young had more than three times the legal drink-drive limit of alcohol in his blood as well as the sedative Diazepam.
In a narrative verdict, Dr Dean said Mr Young died from complications following excessive alcohol consumption when he had taken prescribed drugs. He said he would write to the health trust managers asking that they look into their procedures for managing intoxicated patients.
After the hearing Mr Young’s father, Andy, said: “If you are drunk and in hospital you expect someone to help. Those young men aren’t going in there to die, they are going in there to get well.”