Man died after he missed out on emergency detox
Inquest told of ‘poor communication’ between members of staff at hospital
AMAN died from complications caused by alcohol dependency just days after ‘poor communication’ meant he missed out on an emergency detox.
Matthew Copestick, who had a history of drug and alcohol misuse, collapsed in the shower at his home in Rochdale on January 8, 2019.
Just four days earlier, on January 4, he was taken to A&E at Fairfield General Hospital after falling unwell, an inquest heard.
A triage nurse believed the 21-year-old needed treatment for alcohol detoxification at specialist treatment centre the Chapman Barker unit.
Rochdale Coroner’s Court heard Matthew, who had autism, was discharged as medically fit instead.
“Due to poor communication between staff and a lack of understanding by the alcohol liaison nurse as to the requirements for an emergency inpatient admission to the Chapman
Barker unit Matthew was not admitted for an inpatient alcohol detoxification,” senior coroner Joanne Kearsley ruled.
Matthew was left distressed by the news he wouldn’t be admitted to the Chapman Barker Unit - his father described him having a “meltdown” before he left hospital.
Matthew’s medical cause of death was recorded as
1. A. sudden and unexpected death in alcohol dependency.
2. Alcoholic fatty liver. A post-mortem found that Matt’s liver was significantly enlarged.
Toxicology tests showed that at the time of his death Matt was not intoxicated and there was a very low level of alcohol in his system.
According to the record of inquest, Matthew had a history of drug and alcohol misuse.
At the time of his death he was being cared for by various services.
His alcohol dependency was ‘exacerbated by his Asperger’s,’ according to the record of inquest.
In February 2018 he had been an inpatient for a drug detoxification.
He continued to use drugs, including Spice, for a period of time until he stopped in or around July 2018.
He remained under the local drug and alcohol service Renaissance.
Although he stopped using drugs, his alcohol consumption increased during the summer of 2018 - and he would have to 14-15 cans a day and whiskey.
In September 2018, an urgent referral was made to Turning Point, which provides health and social care services in the town.
Senior Coroner Joanne Kearsley ruled that this referral should have been made in April 2018 ‘given that Matthew was using drugs and alcohol after February 2018.’
Turning Point did not attend key multi agency meetings to discuss Matthew’s alcohol management and treatment plans until December 13.
Matthew asked to have a detox at home, but he was not suitable for this as he was suffering increased seizures.
Despite experts knowing this by November 5, there were no plans in place to organise an inpatient detox until December 13.
On November 6, Matthew was noted to have abnormal liver function test results.
But no consideration was given to provide extra support for him over the Christmas period - during which his drinking increased.
Mr Copestick was described by his parents as ‘polite, engaging, wonderful, kind and respectful’ during the hearing.
In a statement following the inquest, parents Helen McHale and LeeCopestick said:”Having sat through all the evidence it remains clear to us that Matthew did not need to die.
“It is clear that Matt was let down and that better communication, an understanding of how Matt’s autism impacted on him, and listening to us more, would have resulted in a different outcome.
“Days before his death Matt said ‘Mum I want my detox before I die.’ This had a powerful impact then, but it haunts us now.”
Renaissance came under the complex needs service of Rochdale Council in April 2018, the inquest heard.
Sally McIvor, director of commissioning (DASS) for Rochdale Borough Council, said: “We would like to offer our sincere condolences to Mathew’s family and friends for his tragic death and their terrible loss. We accept the coroner’s findings in full and, since Matthew’s death, all operating procedures for vulnerable adults have been reviewed and updated in line with the coroner’s findings.
“We now have in place a specific service that focuses on the needs of vulnerable adults with lifestyle challenges, including addiction issues.
“This is one of the many changes we have made following this tragic incident. We will continue to work in partnership to ensure the wellbeing, support and protection for vulnerable adults across the borough is always our number one priority.”
Tyrone Roberts, director of Nursing and Chief Officer at Fairfield General Hospital said: “We wish to offer our sincere condolences to Matthew Copestick’s family and friends for their sad loss. Our heartfelt sympathies go out to them.
“The Alcohol Liaison service whilst operating out of Fairfield General Hospital is not part of this organisation.
“With a view to generally increasing awareness and understanding as to the Alcohol Liaison Service that operates out of Fairfield General Hospital, we invited the ward manager of the Chapman Barker unit to the group’s quarterly Alcohol steering group.
“This was to ensure Fairfield General Hospital staff were aware of the criteria for the pathways that exist for inpatient detoxification referrals.
“We are committed to ensuring collaborative working with other organisations and it has been agreed that a representative from the Chapman Baker Unit will be invited to attend future meetings.”
Clare Parker, executive director of nursing, healthcare professionals & quality governance at Pennine Care NHS Foundation Trust, said:”We offer our deepest sympathies to Matthew’s family for the loss of their much loved son.
“We accept the conclusion of the coroner and recognise that there are lessons to be learnt.
“We are working on improving communication between teams to ensure all alcohol referral pathways for patients attending A&E are understood. As a trust, patient safety is a priority and we are sorry that on this occasion the referral did not happen.”
Natalie Travis, head of substance misuse and public health at Turning Point said: ““In January 2019, Matthew Copestick, a client at Turning Point’s drug and alcohol service in Rochdale, died of an alcohol related condition.
“Matthew was a young man with his whole life ahead of him. We are extremely sad for his death and offer our deepest sympathies to his family.
“We fully accept the Coroner’s conclusions and any recommendations she makes will be fully implemented. The inquest found that a number of agencies working with Matthew could have made improvements to the support he received. We have learnt lessons from Matthew’s death. Following the investigation in the circumstances surrounding his death we made a number of changes and we continue to work to improve our system and processes.
“Since Matthew’s death, autism awareness training is now mandatory for all staff working in Turning Point drug and alcohol services, we have adapted our programme for clients with autism and improved the processes for drawing on our own autism specialists to work with clients and their families where clients have complex needs including identifying an autism lead in each service who is fully trained and responsible for coordinating our response and approach to people with autism.
“In addition, we have enhanced the support provided to high risk alcohol dependent clients over the Christmas period.”