Learning Disability Today
Supporting professionals working in learning disability and autism services

Coroner rules neglect contributed to Sally Lewis’ death

A coroner has ruled that the death of a woman with a learning disability was caused partly by neglect.

Sally Lewis died as a result of faecal impaction, caused by chronic constipation. It was known that Sally was prone to constipation, and it is something she had been to see her GP about on several occasions.

Sally was 55 years old when she died. She had a severe learning disability and was largely non-verbal, but was able to communicate some basic needs through single words.

She was living at The Dock, a supported living placement in Bromsgrove provided by Dimensions UK, when she died in October 2017.

Sally had lived there since May 2016 and had previously lived at another Dimensions service at Stourbridge Road. In total, Dimensions cared for Sally for more than 20 years.

Support workers received no training in constipation or bowel issues

The inquest into Sally’s death heard that Sally had a prescription for her longstanding issue with constipation since 2016. However, for the 10 months prior to her death, this medication had not been given to her.

The coroner said this was because there was no regime in place to record and monitor Sally’s bowel movements in order for the staff looking after her to judge whether they needed to administer the medication.

Importantly, the coroner noted that Sally’s MAR chart instructed caregivers to administer the medication ‘as required’. This insinuates that the support workers should have used their own clinical judgement, however, none of the Support Workers looking after Sally regularly had any proper or appropriate training on the important issue of constipation and bowel issues.

The coroner said had they had such training, they ought to have, “and probably would have”, known how important it was to monitor Sally’s bowel movements.

The support workers at The Dock said it was difficult to monitor Sally’s bowel movements as “Sally found it difficult for people to accompany her to the bathroom and this could trigger significant behaviours of distress for her.”

However, the coroner said, if this was the case, the support workers should have raised the the issue with the Locality Manager, Julie McGirr, with the Operations Director, Julie Campbell, and with Dr Williamson, Sally’s GP.

The coroner said: “Had a proper regime been in place to monitor and record Sally’s bowel movements, it is likely in my view either sufficient Laxido would have been provided in addition to other medication to relieve Sally’s constipation, or, further advice would have been sought from Sally’s GP. Either way, if a proper regime was in place to monitor and record Sally’s bowel movements, Sally probably wouldn’t have died when she did.”

Dimensions say they have “acted swiftly to make the necessary changes”

In response to the result of the inquest, Rachael Dodgson, Chief Executive of Dimensions, said the care they provided Sally at The Dock “simply wasn’t good enough”.

Since Sally’s death, Ms Dodgson says a “huge amount organisational energy has gone into making things better”. Now, Dimensions provides their care workers with mandatory training on constipation, and it is an organisational requirement that all people they support are regularly screened for constipation and bowel health.

Dimensions have also created a Bowel Toolkit which includes bowel management plans, improved bowel recording charts, a constipation screening and referral tool, guidance on how to prepare for a constipation appointment and more.

They have also moved to an electronic daily records system to make it easier to scrutinise medical records, and have ensured that those directly responsible for the oversight of delivery of individual care and support are closer to the people they support.

Ms Dodgson said Sally’s inquest is an “incredibly sad but important and timely reminder that we must always make sure support plans are clear … and that checks take place to ensure all those things are happening, whether that’s in relation to people’s bowels or any other areas of support.”

“I will end this by simply saying, to Sally’s family, I’m truly sorry.  Nothing can bring Sally back but I’m determined that we will continue to do all we can to minimise the risk of this ever happening to anyone else,” she said.

A member family said that the inquest does not bring the closure they hoped for and they still have many unanswered questions.

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