‘Vulnerable adult’ was failed following a catastrophic injury
AN INQUEST has found that a vulnerable adult was failed by his care home after breaking his neck in a fall.
Heddwyn Hughes, 67, was in the care of Hywel Dda University Health Board.
The inquest into his death concluded that he was failed following a catastrophic injury while detained in a care home for people with learning disabilities. Mr Hughes had a lifelong learning disability, which required full-time care, and he was detained under a Deprivation of Liberty Safeguard.
He was living in Bro Myrddin care home in Carmarthen. The inquest heard evidence that at around 9am on May 6, 2015, Mr Hughes, who was unable to communicate what he needed or how he felt, suddenly lost the use of all four of his limbs after collapsing to the floor while being lifted by staff.
It took around four hours for him to be seen by a medical professional.
It later transpired that he had broken his neck.
A spinal expert told the jury that Mr Hughes was likely to have become quadriplegic at the point of injury.
He died in hospital five and a half months later as a result of his injury. The inquest jury concluded that the injury occurred in his bedroom just after he had walked back from the bathroom with a member of staff, but it was not possible to determine the cause.
The jury also determined that Mr Hughes did not receive appropriate care and treatment from health board staff and was failed by an inadequate protocol, and that the health board did not respond appropriately or with sufficient urgency following Mr Hughes’ injury, or communicate adequately with his GP.
Following Friday’s inquest, Moelwen Gwyndaf, Mr Hughes’ sister, on behalf of the family, said: “At the centre of all this is my brother Heddwyn, who was much loved and whose life required so much support.
“His legacy will be that other such vulnerable adults in the care of the state and who cannot say what has happened to them will have protocols and procedures in place that will ensure their safety and care.
“I would like to thank the coroner and jury for their thorough investigation.”
Clare Richardson, of Deighton Pierce Glynn, who represented the family, said: “This conclusion is the result of three years of remarkable courage and determination by Heddwyn’s family, who have overcome significant obstacles in their search for the truth.”
Dr Warren Lloyd, associate medical director and clinical director for mental health and learning disabilities services at Hywel Dda University Health Board, said: “We wish to offer our sincere condolences to Mr Hughes’ family for their loss.
“The health board accepts the inquest findings and we wish to reassure Mr Hughes’ family that we have taken this matter extremely seriously.
“We have undertaken significant work over the past three years to improve our compliance with expected standards and a protocol issued to staff will be further developed in consultation with Mr Hughes’ family following the conclusion of the inquest verdict and recommendations.”
“The health board continues to invest in improving awareness of the needs of patients with a learning disability and have recently recruited dedicated nursing support to provide advice and assistance in understanding the needs of people with a learning disability, who may be under the care of our general hospital wards and community settings.”