Stephen Dulling
14 Oct 2024 · Coroner Catherine Cundy · North Yorkshire and York
The coroner's concerns
1. lack of practical advice and assistance from crisis line
“I heard evidence that on 29 August 2023, the day after Mr [name redacted] had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs [name redacted] was to call the police if she was concerned for her safety. Mrs [name redacted] ended the call frustrated at the”
2. repetition of limited response
“My concern is that a repetition of such a limited response could present a risk of future deaths to others.”
3. omissions and lapses in basic nursing care
“I heard evidence of a number of omissions and lapses in the care afforded Mr [name redacted] by registered nurses during his admission to York District Hospital. My concerns relate to the following findings -”
4. no direct inquiry of primary carer about nutritional needs
“No evidence of any direct inquiry being made of Mr [name redacted] primary carer in respect of his nutritional needs, despite Mr [name redacted] being deemed to lack capacity;”
5. inappropriate diet recorded and acted upon
“It being recorded and acted upon that a regular diet was appropriate for Mr [name redacted], despite a) above;”
6. absence of food chart
“No food chart being implemented and maintained despite the outcome of Mr [name redacted] malnutrition risk assessment;”