An inquest into the death of 41 year old William Johnson who had lived in St Andrews for 18 years, heard 3 other men on his ward had predeceased him, exhibiting similar symptoms and on the similar medication.
The first death was on October 23rd 2010, second March 31st 2011, third April 3rd 2011 and then, Mr Johnson on May 31st 2011.
4 deaths, half the 8 bedded ward, in just 8 months.
This ward was costing the tax payer £ 36,000 per week tax free.
I think this figure needs to be revised if this as I think it was a locked/secure ward where the standard fee for mental treatment is now £13,000 per week.
So back then the figure was likely to be nearer a staggering £96,000 per week.
A Coroner, delivered a narrative verdict on Mr Johnson’s death.
And he refused to reopen the inquest.
The only other inquest into the previous deaths had recorded death by ‘natural causes’.
Narrative verdicts were created in 2004, and merely describe the circumstances of a death not how it was caused.https://en.wikipedia.org/wiki/Narrative_verdict
Dr Adewale Aromolaran, the senior doctor, in charge of the ward, when Mr Johnson died told the inquest,
He was not involved ‘in any discussions about the three previous deaths’,
Despite Mr Johnson’s similar medication and similar physical symptoms.
Yet ‘Parallels’ between the deaths were noted by the inquest.
However, Dr Aromolaram was made aware, of the second, and, third deaths, on his becoming a member of the ward ‘team’.
But despite the quick succession of deaths, the last 2 men to die before Mr Johnson, dying within four days of each other, and Mr Johnson, ‘ vomiting large amounts of body salts.’
As his organs, slowly, filled up with a faeces impaction, a common condition in the autistic per se and a side effect of the high dosages of at least two different antipsychotics.
The doctor alarmingly gave evidence at the inquest that;
“There were no discussions. No talks at all about those deaths that I was involved in”.
All men were medicated with clozaphine which is known to cause constipation.
So, the managing doctor, of an 8 bedded ward where 3 deaths had already occurred in only 7 months before he became part of the ward management team was not informed of the first death, nor discussed the similarities of the second and third.
Nor, even, more crucially, did the doctor connect this latest death with the two deaths, less than 2 months before William Johnson, who like William would have been presumably also ‘vomiting up large amounts of body salts’.
And, worse stilldespite a 3rd death, the hospital appeared to have taken no precautions, to find out the reasons, nor change the treatment of the others in the ward.
The medication was continued in the same high dosage to people incapacitated, throwing up permanently in bed.
How can this be ‘treatment’ ?
And why did no one check on the physical health of these successively dying men as they were obviously seriously ill, throwing up and no doubt in constant agony.
The ‘hospital’ being paid a small fortune likely over £80,000 per week.
The doctor gave evidence, that it had been impossible even to ‘try’ to examine Mr Johnson’s abdomen during a ‘routine’ health check as he would not let the examination proceed.
How likely is it that a man, bed ridden full of chemical coshes, vomiting up salt, would/ could/should have not allowed a hand on his bowel area easily able to pick up such a serious impaction, which should in any event, should have been picked up from vomiting salt, the side effects of medication and three previous deaths in similar circumstances in less than 8 months ?
And if continual medication can be enforced why not a life saving examination ?
Did no one ask why all these men were vomiting up body salts ?
And, in any event, would such a ‘routine’ health check have checked for and detected an impaction. ?
And, why, was only a ‘routine’ health check, thought sufficient, when this man was obviously dying, in the same manner, in the same ward, as his 3 fellow ward occupants, in quick succession ?.
How many ‘routine’ health checks, are tick boxed refused, and, who actually performs them ?
On this basic safety/ care issue, staggeringly, Dr Aromolaram, was not aware of any hospital strategy in place, if a health check was refused.
St Andrews glossy PR is on the internet http://www.standrewshealthcare.co.uk/sites/default/files/documents/12136_SAH_Quality%20Accounts%20A4%2044pp_V13%20(final_reduced%20size).pdf
The tax payer, was, paying at least £9,000 per week for this ‘treatment’, when charitable tax exemption is factored in.
We do not know the figures that is charged and paid for with our public money.
The Priory and Cygnet charge a minimum of £900 per night and up to £12,500 a week for an autistic 15 year old in an acute mental health bed.
See the structure of the provision and ward system here:
St Andrews, had a turnover of £187.5million in 2013/14.
And, its chief executive at the time was earning £675,000 per annum.
The service was private, and commissioned and paid for by NHS England.
3 learning disabled, a day, died of inadequate NHS care, last year- that’s a staggering 1200, and, it was probably more this year.
And, billions of profit has been made from their care.
Care Quality Commission Report 2014 see summary – Requires Improvement.
See summary. http://www.cqc.org.uk/sites/default/files/1-102643363_coreservice_child_and_adolescent_mental_health_services_st_andrew_s_healthcare_scheduled_20150107%20%281%29.pdf
Since the deaths St Andrews have been forced to acknowledge the role medication might play