The curious incident of the earlier death in the bath

In June 2006, HC, 57, died unexpectedly in the same bath that LB died in. Days after two ECT treatments he was unable to consent to. This emerged during LB’s inquest in October 2015. The coroner, who was clearly surprised to hear about the earlier death requested statements from the key three people involved in HC’s death.

  • The student nurse present in the bathroom

Once I had H supported I managed to pull my alarm, whilst at the same time shouting for assistance. At that point a member of nursing staff entered the bathroom, it was a female member of staff but I cannot recall who it was, simply due to how long ago this incident occurred. I can however recall that [nursing manager] followed that female in to the bathroom. It was approximately 10-15 seconds from H starting to have a seizure to other staff members joining me in the bathroom. By the time they arrived the water was drained and H was still in the bath and [nursing manager] told me to leave the room, which I promptly did. I understand that he did this purely because of my age and experience and he felt it was best to be away from what was happening to H. I did not see what happened next and never saw H again.

  • The nursing manager 

At the time of the incident I know I was not on the Unit.

Later in his statement he says:

I am not sure if I arrived there before Dr J or after but she went into the bathroom and assisted in trying to revive patient. I also cannot recall whether paramedics were already present when I arrived at the ward or whether they arrived after.

  • 3. Dr J (who phoned me the day LB died)

As the attending doctor, I pronounced HC dead.

Later in her statement she says:

On 29 June 2006, I received a phone call from the HM Coroner’s Office asking me if I was prepared to complete and signed the Part 1 of HC’s Death Certificate as I was the attending doctor at the time of his death. They called me again after 15 minutes and informed me that the HM Coroner was not going to ask for a postmortem examination and open an inquest. They informed me that HM Coroner would sign the Part II of the Death Certificate.

The 2014 Sloven ‘investigation’

Another Sloven psychiatrist was tasked with finding out more about HC’s death in 2014. He wrote to the Sloven Clinical Director on March 25 stating:

[Dr J] confirmed that there had been a death some years before Dr M’s appointment. [Dr J] relayed that the circumstances were different in some respects to the epilepsy related death last summer, but similar in that an inpatient on STATT had a seizure in the bath. An attempt at resus followed but it was complicated by the difficulty staff had extricating the man from the bath. He died soon after.

On May 13, the Sloven ‘inquiry’ concluded:

As this was an unexpected death of an NHS inpatient it was reported as a SIRI. There is no evidence of an RCA being undertaken. The Coroner had pronounced the death as natural causes.

This is how you erase a life and a death in full view. Particular lives and deaths. Those that don’t count.

12 thoughts on “The curious incident of the earlier death in the bath

  1. Coroners seem to be increasingly useful to unsafe NHS services. Things were getting a bit difficult for the north Wales mental health services a few years ago because so many people up here were committing suicide that it was noticeable as a statistical outlier and no-one could explain why rural north Wales should have such a problem. Then I noticed that coroners were increasingly returning narrative or open verdicts on people with mental health problems who had been found dead. The north Wales mental health services have recently proudly announced that rates of suicide here are now no higher than in other areas. Likewise the CEO of the Health Board in north Wales recently gave a media interview in which he maintained that death rates of people in the care of the mental health services were not higher than in other regions. The fact that the mental health services here have now collapsed and its damn near impossible for a lot of people to actually obtain secondary psychiatric care (and that high numbers of patients are being sent to England for treatment) was not mentioned.
    Problems solved!

    • Coroners in Hampshire have been useful to Sloven for at least four years. They appear never to report, for example, doctors to the GMC – even when one shredded a patient’s notes before the Inquest into the death of Victoria Nye, which is tantamount to perverting the course of justice. The GMC heard about it circa 2/3 years later from me – but by then he had deregistered in the UK presumably to work abroad. When I asked the Coroner’s Manager what the Coroner had done, he told me the Coroner just sent everything to the Care[less] Quality Commission for them to sort out. That explains a lot! In this case, I believe the Coroner should have reported it direct to the police as well as to the GMC. Who knows – if that Coroner had made a report to the police, it might have taught Sloven a valuable lesson to tighten up their data security. Instead, many have suffered from lost/missing/withheld documents for the last four years – including in respect of further Inquests.

  2. How many more cases of avoidable deaths of people with a learning disability and autism are we to tolerate before it’s accepted that NHS MH Trusts are not the place for our most vulnerable citizens. The NHS should exist just for general medical treatment. These Trusts have proven they are irresponsible and incapable of recognising that people with an intellectual disability are equal in law and share the same human rights as every other citizen in the UK.

    • They’re usually NHS LD services within a Trust (not MH Trusts), although yes, MH Trusts are more inappropriate.
      But as said by many, many times, there’s little treatment or assessment that even sounds useful. But lots of time in baths..
      Unlike ‘normal’ patients, these patients don’t know their rights.
      But families are ignored too.
      This must stop.

  3. No wonder Sloven were so quick (and keen) to pronounce LB’s death ‘natural causes. Standard bloody procedure, never mind the specific circumstances of the death. Was there anybody in the bathroom with ‘H’, or was he also left to drown in allegedly dignified isolation?

  4. The very first rule in epilepsy with people who have tonic clonic seizures is THAT YOU NEVER HAVE A BATH. How simple can that be. Does no one know what a tonic clonic seizure is – the muscles go into spasms, the patient falls forwards or backwards, water fills their lungs, they drown. Many people who have tonic clonic seizures also cyanose..

    • The HSE will not look upon HC’s death as a ‘ surprise’ , it is an earlier incident directly linked to Connor’s wholly preventable death and it was not investigated. Paramedics and the police should have attended. The nurse’s account of having H supported sounds very odd. Supported how ? and how was support of H transferred / maintained by those next on the scene ? HC deserves a comprehensive investigation into his death , the staff must be interviewed.

  5. Also a bath in a hospital!!!! What about hygiene – what about health and safety. This is 2016 – a wet room, not a bath

    • My son was often left in the bath for an hour or more in hospital, as staff ignored him and chatted. He used to get very frustrated.
      Staff in the community have left him for much longer (because the hospital taught them the wrong thing), saying he likes that. I can’t police them – they do as they like. It maddens me to know how expert we parents are, and how our hands are tied.
      The whole thing is a mockery.
      We could have safe chairs in high surround baths, so people can’t easily drown. With regular checks for infection.
      For sensory needs there should be dry flotation beds – we must plan therapy that OTs don’t think of – we should lead the way.
      If others can’t be bothered, we have solutions.
      We are a ready task force, I feel – Task and Finish.

  6. Interested to see reference to tonic-clonic seizure – Sloven knew about the dangers of tonic-clonic seizures in 2011 but did nothing about it. I know – I was a ‘victim’ of Sloven. I had a tonic-clonic seizure (1st) that year but fortunately survived. Moreover, their muppet psychiatrist tried to assess my mental health within 6 hours of the seizure (which is impossible to do accurately) and, as a result, sectioned me without lawful justification – an offence that is a tort of strict liability and has been since the Magna Carta. In addition, the GMC found that he lied on the section form. It was determined subsequently that I was not mentally ill at all – yet Sloven refuses to accept that I was detained unlawfully.

    If a police officer lied in this way in detaining a person (as happened in the Plebgate affair) he would be suspended and probably prosecuted for misconduct in public office. What happens at Sloven – do they even suspend the psychiatrist. NO! They appoint him to the Clinical Ethic Committee!

    In short, I was falsely imprisoned and Sloven will not accept it: they work on pre-12th century law. In two other cases, Sloven’s latest stunt is to appoint as an ‘independent’ investigator of two complaints – John Dale – who is Chair of the NHS Complaints Manager’s forum, of which Southern Health is a member – in effect he is sitting in judgement on one of his members. He has also written that he, “Will do his best” to be independent – in other words he will not guarantee his independence.

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