Many of us who have been following the unfolding Inquest concerning the death of Richard Handley, are not surprised that the Coroner found gross and significant failures on the part of those caring for him.

This language has a special meaning in the Coroner’s court and is usually the precursor for a finding of Neglect.  Neglect is not a conclusion in itself but will often be determined when the cause of death is natural, but there is a clear and direct contribution to the death by avoidable acts or omissions. 

Neglect, in this context, means a gross failure to provide adequate nourishment, liquid, basic medical attention, shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration), who cannot provide it for themselves. Failure to provide medical attention for a dependent person whose physical condition is such as to show he obviously needs it may amount to Neglect.  It is very important to appreciate the importance of the obvious need and dependency of the individual. 

In this case, Richard Handley’s problems with constipation were well known and had been managed until the nature of his care changed from residential to a supported living arrangement.  However, it appears that whilst the Coroner criticised the overall missed opportunities leading up to his admission to hospital and despite the language used, there was no finding of Neglect. 

It is not enough to show that there has been a missed opportunity to render care that might have made a difference, it must be shown that the care should have been given and that it would have saved or prolonged life.  It is likely in this case that the Coroner could not point to a specific failure in this regard and that is why he did not determine Neglect.

Whilst this has been a disappointment to the family, the focus of the inquest is to establish how Mr Handley came by his death. Often the outcome is less important than the journey taken in order to obtain the necessary evidence to come to that conclusion.  It should be remembered that the Inquest is a fact-finding exercise and although it will investigate culpable behaviour, it is not the forum to apportion blame.  

Richard Handley’s avoidable death is tragic, and his family must be devastated. They should hopefully, in time, find some solace in the knowledge that there has been scrutiny of the differences in the nature of care given when stepping down from residential care to a supported living environment (presumably with assessments being undertaken as to his care needs) and of course the overarching communication problems for people with Learning Disabilities.  There are many vulnerable people who need to access medical services and who are not able to express themselves clearly.

The CQC's review (before the Inquest) looked at NHS trusts in England providing acute, community and mental health services.  Placing a particular focus on people with mental health conditions and learning disabilities.  The review found that:

  • The level of acceptance and sense of inevitability when people with a learning disability or mental illness die early is too common.
  • There is no consistent national framework in place to support the NHS to investigate deaths.
  • A failure to prioritise learning from deaths so that action can be taken to improve care for future patients and their families.
  • Many carers and families do not find the NHS to be open or transparent.
  • Families and carers are not routinely told what their rights are when a relative dies, what will happen or how they can access support or advocacy.

So what does this all mean?  It is clear that there were missed opportunities by all those who were caring for Richard Handley in the last five years of his life. There was no joint approach to his care.  He was seen by healthcare workers, a general practitioner, district nurses and of course finally treated in hospital.  The Coroner could not, therefore, single out any one failure but his investigation revealed a systemic failure in dealing with a vulnerable person unable to communicate effectively for himself.

We do hope that now that the inquest has concluded, there will be positive steps taken to do more to join the health and care services provided for people like Richard Handley to ensure that communication and services improve.  It is not known at the time of writing whether there have been such recommendations by the Coroner exercising his statutory duty to issue a Report for the Prevention of Future Deaths, but it would be surprising if there was not. If and when a report is published we will provide a further briefing.

Further information

If you would like to find out more information about the issues raised in this article, please contact Sarah Knight