‘Inaccurate’ Communication Contributed To Hinckley Woman’s Death, Inquest Finds

Leicester Coroner’s Court has, this week, criticised healthcare professionals at the Bennion Centre at Glenfield Hospital after a 68-year old pensioner died from a pulmonary embolism caused by DVT while in the hospitals’ care, an inquest has heard.

Background

Cherry Dunn, of Hinckley, was diagnosed with a water infection by her local GP in September 2018. This led to her becoming unwell and experience delirium, resulting in her being taken to Leicester Royal Infirmary’s Accident and Emergency (A&E) department on 3rd October after a fall at home, it was on this date that it was discovered she had water retention and was placed on the assessment unit. She was seen by the Frail Older Peoples’ Advice and Liaison (FOPAL) service before being moved to another ward. It was during this time that her husband, Martin, noticed that her legs had started to swell up and that she had bruises on her legs and arms.

She was admitted to the Bennion Centre at Glenfield Hospital, a mental health unit, on 24th October, under section two of the Mental Health Act 1983, a move that was arranged by the FOPAL service as Cherry was showing signs of confusion.

The following day, Cherry experienced a second fall, which resulted in a brief return to Leicester Royal Infirmary. In the days leading up to her death, Mr Dunn said his wife had become less mobile and her mental health had deteriorated, with her being more lucid on some days than others.

It was two and a half weeks after her admission to the Bennion Centre, on 5th November, that Cherry suffered the fatal pulmonary embolism caused by DVT and passed away in her room.

A month after his wife’s death, Mr Dunn was informed of an investigation and later provided with a report in June 2019, where he concluded that Cherry “should not have actually died”.

Inquest

At a six-day inquest into Cherry’s death, which concluded on 19th August at Leicester City Hall Coroner’s Court, the coroner, Professor Catherine Mason, and the jury found that, on the balance of probabilities, the incomplete, inaccurate and insufficient records and verbal information communicated between healthcare professionals at The Bennion Centre, combined with Mrs Dunn’s lack of engagement due to her mental health, prevented proper investigations being made and, ultimately, contributed to her death.

The hearing was a Human Rights Act (HRA) Article 2 Jury Inquest. This is an enhanced inquest, which is held in cases where the state or ‘its agents’ (in this case, Leicestershire Partnership NHS Trust) have ‘failed to protect the deceased against a human threat or other risk’ or where there has been a death under some form of detention, such as the Mental Health Act.

Mr Dunn, who had been married to his wife for 42 years before her death, said:

“The day Cherry died, I arrived at the Bennion Centre to be told I had missed her passing by 12 minutes. They told me that she had had a heart attack and asked me if I wanted to see her, to which I agreed. I was taken to her room where she was on the floor by her bed, lying on her back. Her eyes were wide open, she still had the airway respirator wedged in her mouth and a plastic sheet was laid over her. After speaking to a police officer in another room, I returned to say my goodbyes and Cherry had been put into her bed.

“Following Cherry’s death, I was informed there would be an investigation and in June 2019 I was given the report. The more I read it the more I thought that it sounded like Cherry should not have actually died.

“My wife had never had any major illnesses and, in the years before her death, she had been fit and well enjoying time at our apartment in Fuerteventura. She had many friends there, would walk a lot and ride a pushbike. She was involved in a charity that looked after local stray cats and also helped the RSPCA with various fundraising events.

“I continue to repeatedly see the scene with Cherry lying on the floor in her room, and I cannot seem to move on from it. We had planned to spend more time together in Fuerteventura once I retired. I retired in July 2019 but sadly now, that future has gone.”

Matthew Olner, Partner and medical negligence specialist from our Leicester office, has been assisting Mr Dunn with the inquest since November 2019. Barrister John Hobson of Doughty Street Chambers has been representing him during the six-day hearing.

Matthew said:

“Upon her admission to A&E on 3 October, she was diagnosed with water retention, something that – if combined with prolonged inactivity and other factors, such as dehydration – can allow blood to stagnate and become clotted and lead to DVT, as it did with Cherry.

“Mr Dunn had expressed his own concerns with his wife’s mental state and her treatment while in hospital both at Leicester Royal Infirmary and at the Bennion Centre. He had been visiting her in hospital every day since she was admitted.

“While at the Leicester Royal Infirmary he never witnessed anybody mobilising Cherry. He only once saw her go to the toilet, and she was pushed in a wheelchair to get there, and noted the swelling of her legs and bruises on her body.

“After she was transferred to the Bennion Centre on 24 October, he went in to see her the following day to be told she had been taken back to the Leicester Royal Infirmary because she had fallen over and bumped her head. He is unsure whether this was because she had been allowed to walk unaided, something which she had not done during her time at Leicester Royal Infirmary.

“After she returned to the centre the following day, whenever Mr Dunn visited his wife, she was always brought to him by two people. She seemed to be spending most of her time in her room, which she shared with another woman, sitting on her bed and did not want to eat or talk.

“The jury’s findings meant a great deal to the family as they recognised, and criticised, the lack of communication between those in charge of Cherry’s care and how it contributed to her death. A civil claim is already underway and ongoing against the Trust, and we hope that Mr Dunn can begin to find some closure as a result of these findings.”