‘Sub-optimal’ care didn’t cause man’s death at hospital
INSTANCES of “sub-optimal” care by hospital staff did not contribute to the sudden death of an 87-year-old man, a coroner has found.
Derek Hood, from Barry, died at University Hospital Llandough in the early hours of October 18, 2019, after being found hanged in his room in the hospital’s mental health unit having been admitted there two months earlier following a previous suicide attempt.
A four-day inquest at Pontypridd Coroners’ Court heard Mr Hood was being checked far less frequently at the time of his death than he was when he was first admitted as staff on the ward did not believe he was at risk of suicide or harming himself.
It was also revealed that a meeting to assess Mr Hood’s level of risk ahead of him being discharged from hospital was due to take place in the week before his death but never went ahead.
Eight witnesses involved in the care of Mr Hood appeared in court to give evidence while a further 14 people submitted evidence that was heard by the inquest including the deceased’s nephew Michael Ceshion who said that his uncle had told him that that “one part of him wanted to live and another wanted to die” before his death.
The inquest also heard that Mr Hood had initially been on “one-toone” observations having been admitted as “high-risk” meaning that he was accompanied by a member of staff at all times – including when he slept and went to the toilet.
However, as he became deemed less of a risk, the frequency of these observations was reduced to every 15 minutes and later to once every hour.
At 2.20am on October 18 a member of staff on the Daffodil Ward at the hospital went to check on Mr Hood and, upon entering his room, discovered him lying unresponsive on the floor having hanged himself. Attempts to resuscitate him were carried out but stopped at 2.49am.
Mr Hood had been admitted to the hospital in August 2019 having attempted to take his own life. The inquest heard how he had become depressed after a botched eye operation – in which his “good eye” was mistakenly operated on instead of his bad one – saw him lose his sight almost completely while he was already partially deaf.
Returning his conclusion yesterday senior coroner for South Wales Central Graeme Hughes said there were some areas of “sub-optimal” care given by hospital staff on the ward but these did not cause or contribute to Mr Hood’s sudden death.
A medical cause of death was given as 1a. pressure on neck (incomplete hanging).
Recording a narrative conclusion Mr Hughes said he had no direct evidence of Mr Hood’s intention to take his own life but was satisfied that he had acted deliberately and alone even if it was impulsive.
“The deceased died due to self-ligature and his intention at the time was unclear,” he said. “While there were aspects of the care given to Mr Hood that may be considered suboptimal there were no failures in that care that were contributory or causative to his death.”
The coroner added that he had directed health board directors to provide a written update on the implementation of new measures highlighted by the case, such as risk assessment procedures on the ward, which is set to be returned in April 2022.
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