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15142_clinical_neg_update.fh11 23/1/08 10:22 Page 1 Inquest into Death at HMP assessment, planning and communication, contributed Martin’s family believe that his death was unnecessary andavoidable. The family, which has waited five long years for Nelsons has acted for the family of 25 year old Martin justice for Martin, were satisfied that the jury shared their Green from South Derbyshire, who died from dehydration concerns as to Martin’s appalling treatment.
in HMP Blakenhurst on 15th July 2002 while serving a12 month sentence for motoring offences.
During the 22-day inquest into his death, held before HMCoronor for Worcestershire (Geriant Williams), Nelsons The firm has recently acted on behalf of a client who initially represented Martin Green’s partner Rachel Briggs and their intended to bring a claim against her GP as, two weeks after four children. The jury found that the medical care Martin attending her GP surgery complaining of a headache and received was inadequate and serious failures in his treatment generally feeling unwell, she suffered a stroke.
The client was admitted to hospital having suffered a Martin was found dead in his cell in the prison healthcare catastrophic stroke which has left her hemiplegic. At the centre where he was undergoing detoxification for drug hospital, it was diagnosed that she had a predisposition to addiction. At the time of his death he weighed just 6st 10lbs.
strokes as she had been, for some time, suffering from a clotting The cause of death was dehydration and electrolyte disorder called Anti-phospho-lipid Syndrome (APS). It waslikely that she had been suffering from this condition for many imbalance, as a consequence of repeated vomiting. He was also found to have two duodenal ulcers.
Looking back through her medical records, it was discovered This case raised very serious questions about the quality that she had attended another hospital four years earlier when of prison healthcare. Martin was owed a particular duty she had been suffering with pneumonia. She had had a blood of care while in the custody of the state and that duty was test on that occasion and the blood test showed that she had a clotting disorder which, had it been investigated further, Labeled just another druggy by the prison, nursing and would have probably been shown up to be APS. Had she started medical staff that came across him, no-one believed Martin on anti coagulant medication at that stage, it is likely that this when he told staff that he did not have the normal symptoms would have prevented her suffering a stroke.
of withdrawal. Long-standing stomach problems were not The case was recently settled for a substantial fixed figure.
investigated and despite his requests Martin was not takento hospital. On 14 July, a doctor was sufficiently concernedthat he arranged for Martin to go to hospital for IV fluid treatment, but the transfer did not happen due to prisonstaffing problems on that day. Martin was found dead the next morning. All the expert evidence is that he probablywould have survived with an IV line carrying fluids and Over the years, the firm’s Clinical Negligence group has developed a working relationship with AvMA. As a result ofthis, we are able to draw upon the resources that AvMA have The jury’s narrative verdict was highly critical of the to help us with our cases and to help our clients.
treatment Martin received, concluding that “there was ageneral lack of management support and teamwork… the If we require help with recommending an expert or barrister frequency of vomiting and lack of hydration in someone or with research about a case, we are able to ask AvMA with an extremely low body mass index, coupled with poor 15142_clinical_neg_update.fh11 23/1/08 10:22 Page 2 Death by Natural Causes in Circumstances of NeglectNelsons has represented the family of Winifred Dalton had not had her medication. Mr Dalton had eventually following her death from septicaemia caused by clostridium found a doctor, who had made a complaint about the lack difficile (C-diff) infection. The inquest was held before HM of nurses and the medication not having been recorded on Coroner for Coventry (Mr David Sarginson) in which a jury the prescription chart. Extra nursing cover had then been returned a verdict of death by natural causes in the presence of neglect under the care of two Coventry hospitals.
On the morning of 22nd December 2005, Mrs Dalton had Claims of neglect whilst she was at the Caludon Centre and suffered a fall and the doctor in the Caludon Centre was former Walsgrave Hospital, centred on whether tests for sufficiently concerned that her physical condition was such C-diff should have been taken sooner and whether the delay that she should be transferred to Walsgrave Hospital. The doctor there had disagreed and had refused to take a transferat that point, pending further investigation. Part of that Mrs Dalton was 69 when she was admitted to Walsgrave further investigation was the taking of a blood sample, Hospital in November 2005 and was sent home on 26th which got left in the wrong box in the pathology laboratory November without any clear diagnosis. She was then re- (although, as it happened, this omission was not causally admitted to a different ward, with the consultant in charge relevant to death). Later that day, Mrs Dalton’s condition of her care describing her as largely a “social” admission.
had deteriorated such that she was sent by ambulance to During this admission, her family became aware that she Walsgrave, was admitted but with poor prognosis and she died of septicaemia caused by C-diff infection on 23rdDecember 2005.
The family was given a bag of soiled laundry to take home,which they discovered contained clothing soaked in half a Evidence at the inquest was that none of the nursing staff litre of diarrhoea. Following this, the family had telephoned at the Caludon Centre had heard of C-diff and that when the hospital to complain and ask that they provide hospital given the name of the condition, had to download underwear and pyjamas to Mrs Dalton, since she was still information about it from the hospital computer. The suffering from diarrhoea. Notwithstanding this, the nursing coroner called an expert in C-diff, Professor Wilcox, who notes did not contain any observations that Mrs Dalton was had been instructed by one of the hospital trusts involved.
suffering from diarrhoea. In fact, as the jury found, this The family had, for various reasons, not invited the coroner to call other expert evidence. Professor Wilcox was of theopinion that the C-diff infection was hospital acquired and Before going into hospital, and well into her admission, had based his opinions as to when on the nursing Mrs Dalton had been receiving two “broad spectrum” observations of diarrhoea. He expressed the opinion that antibiotics, cephalexin (9 to 23 Nov) and co-amoxiclav starting treatment from 14th December had not made a (“augmentin” – 20 Nov to 5 Dec). She had also been given difference to the outcome and maintained this view even omeprazole for vomiting and lactulose for constipation when pressed about possibly earlier dates of infection.
Professor Wilcox did however state that this was the matterupon which he was least confident. The prescription of broad-spectrum antibiotics (especiallyaugmentin) and also Mrs Dalton’s age, made her particularly The jury unanimously returned the verdict of death bynatural causes in circumstances of neglect. Furthermore, susceptible to infection with C-diff, the principal physical the coroner said he will use his powers under rule 43 of symptom of which is diarrhoea. The presence of C-diff can the Coroners’ Rules to report a number of matters be detected by a simple laboratory test of a stool sample, concerning the quality of care received by Mrs Dalton in which ought normally to take 24-48 hours to come through, hospital and would write to the hospitals involved and also but Mrs Dalton was not tested until much later.
the Secretary of State for Health about his concerns.
On 9th December 2005, Mrs Dalton was transferred to apsychiatric hospital, the Caludon Centre. The family saidthat her diarrhoea had continued there, confirmed byentries in nursing notes and in notes taken by her doctor.
The clinical negligence team at Nelsons has a national On 12th December, a stool sample was taken and sent to profile and is one of the few firms franchised by the the laboratory to be tested. Results were obtained on 14th Legal Services Commission (LSC) for clinical December showing that her diarrhoea was positive for negligence claims. We can advise from any of our C-diff. However, that lab result was placed on a computer three offices on birth injury claims, mis-diagnosis, to which the nurses did not have access, the doctor who complication during surgery or cases where wrong had ordered the sample was away for five days and the or faulty medication has been given.
piece of paper recording the result was not taken to theward but put in a correspondence file. Accordingly, it was We are also on the LSC’s Multi Party Action Panel not until 19th December 2005 that Mrs Dalton started and have members of the Association of Personal receiving treatment with metronidazole, the principal Injury Lawyers (APIL), and the Solicitors Regulation treatment for tackling C-diff infection.
Authority Personal Injury and Clinical NegligenceAccreditation schemes. We also have members of On 21st December, Mrs Dalton’s husband had attended the special interest groups such as the Child Brain Injury ward and found his wife lying in her own faeces, with no Trust, Headway and Spinal Injuries Association.
nursing staff available and his wife telling him that she

Source: http://www.nelsonslaw.co.uk/cms/document/Clinical_Negligence_Update_January_2008.pdf