The inquest has today concluded into the death of Laura Booth with the coroner recording a narrative conclusion that Laura went into the Royal Hallamshire Hospital for a routine procedure, she became unwell and developed malnutrition due to inadequate nutrition.

The coroner found Laura's death was contributed to by neglect on the basis of a finding that there was a continuing gross failure not to provide adequate nutrition for Laura between 29 September and 19 October 2016 when Laura died. In making a finding that neglect contributed to Laura's death the Coroner was satisfied that the failure to provide adequate nutrition to Laura was a gross failure, which more than minimally contributed to her death and that, if the failure had not taken place, the outcome on 19 October 2016 would have been altered.

Our involvement

We were first instructed in relation to this inquest in early 2018, the Coroner had listed a pre-inquest review hearing after being approached by a BBC journalist seeking an explanation as to why Laura's death had not led to an inquest in the first place. It appears the concerns regarding her care had not been known or understood by the Coroner originally. Following a number of pre-inquest review hearings and a pause in proceedings whilst an Independent Investigation authorised by NHS England took place, the inquest commenced earlier this month.

Laura, who was 21 when she died, liked people, socialising, shopping, handbags and helping her parents around the home. Laura, who communicated using a combination of makaton and some verbal and non-verbal communication, was born with Partial Trisomy 13 and diagnosed with a learning disability, communication difficulties and a number of medical conditions. Laura's parents, Ken and Patricia, were her devoted full-time carers and they lived together at home in Sheffield. When Laura was admitted to hospital on 25 September 2016 she was accompanied by her parents who did not leave her side. 24 days later Laura died.

Failures in Laura's care

Laura's family told the Coroner that Laura had been off her food for a period prior to admission and was not eating food in hospital. The Coroner also heard there was no evidence that there was a single day, throughout her whole admission to hospital, that Laura received her required daily calorie intake. Attempts were made to feed Laura orally via food and nutritional supplements (some of which were not suitable to Laura due to her food intolerances). These were not successful. The Coroner made a finding after hearing the evidence that feeding charts, a tool to monitor a patient's nutritional intake had not been commenced.

Total Parenteral Nutrition (TPN) which involves providing nutrition directly into a person's bloodstream, was first considered by the clinicians on 29 September 2016. The Coroner heard evidence dieticians, TPN pharmacists, and various medical doctors were all involved at various stages in Laura's admission considering the issue of her nutrition. Despite numerous discussions, no decision was made to start TPN until the day Laura died. The Coroner heard evidence from an independent expert gastroenterologist that in his opinion TPN should have been started sooner and that he found no evidence that the risk of permitted malnutrition was considered.

Best interest meeting and the Mental Capacity Act 2005

The Coroner has also heard evidence that best interest meetings, a legal requirement, did not take place. Best interest meetings are required where a patient needs help in making decisions about their care due to their mental capacity. Such meetings should have included input and discussion with Laura's parents, who knew her best. This opportunity was lost. The Coroner has made a finding that the decision making in relation to Laura's care was not in accordance with the Mental Capacity Act 2005 and was therefore unlawful. The Coroner will write a preventing future deaths report to address the lack of knowledge and understanding of the Mental Capacity Act in the Trust and seek to ensure improvement in this area.

Progress needed in the way patients are cared for

The evidence heard during the inquest and during previous investigations into Laura's death shows that there were deficiencies in her care, that she did not receive adequate nutrition and the Coroner's conclusions show that progress is required about the way care to patients with difficulties like Laura is given and how decisions are made about that care. Importantly in respect of how a vulnerable person's family or carers, who know them best, are involved in that decision-making process and their concerns listened to.

We are pleased to note that the Coroner has made findings that recognise the severe concern Laura's parents had about her care and the way they themselves were undervalued as experts in the care of Laura. We are also pleased to note the changes that have already been made at the Trust regarding the nutrition processes and we welcome the Coroner's proposals to promote a better understanding of mental capacity issues both at the Hospital Trust in this case but also more widely with her Coroner colleagues.

We are sadly all too used to hearing reports of cases where proper care or treatment is not given to the most vulnerable members of our society and recognition that lessons need to be learned. We hope that some actual positive change can now be achieved in Laura's memory and that the lessons identified by the Trust themselves and the Coroner are in fact learned.

For more information

Please contact David Evison.