Mental health patient's death preventable - coroner

Kevin Ince was under the care of Kemple View Hospital when he died

A mental health hospital could have prevented the death of a man who died after refusing treatment and food, a coroner has said.

Kevin Ince was detained under the Mental Health Act at Kemple View Hospital in Langho, Blackburn, last year.

The 55-year-old died from heart failure linked to lung injuries associated with vaping on 25 October 2023 at the Royal Blackburn Hospital, an inquest heard.

Area coroner Christopher Long said The Priory Group, which runs the 90-bed Kemple View mental health unit, did not do enough to persuade Mr Ince to get the appropriate medical treatment he needed for his condition.

Mr Long, area coroner of Lancashire and Blackburn with Darwen, has published a prevention of future deaths report.

In the report he raised concerns of evidence of "regular refusals of necessary and appropriate medical treatment" by Mr Ince and "insufficient action taken when he routinely declined food over a prolonged period", while detained under the Mental Health Act 1983.

Future risk

Mr Ince pressed a call bell to tell Kemple View staff he was feeling unwell on 24 October 2023, the coroner said.

Staff noted he was short of breath and panting and oxygen was administered until an ambulance arrived.

Mr Ince was taken to Royal Blackburn Hospital where he continued to be supported with oxygen.

Whilst in hospital he underwent a series of diagnostic tests but his condition deteriorated, and he did not recover.

Mr Long said Mr Ince died as a result of heart failure, linked to lung injuries caused by use of e-cigarettes, or vapes.

Mr Long said: "During the course of the inquest the evidence revealed matters giving rise to concern.

"In my opinion there is a risk that future deaths could occur unless action is taken."

A hospital spokesperson said: "We would like to reiterate our sincere condolences to Mr Ince's family for their loss.

"We strive to support patients in the least restrictive way possible, in line with the statutory framework. This includes enabling patients to maintain their independence and make informed decisions for themselves, including on issues such as dietary preferences or vaping, as an integral part of good mental healthcare.

"In light of this case, we reviewed and enhanced our processes to provide increased support for staff in their documented approach when a patient declines physical health checks and a nutritional diet, whilst carefully balancing this complex area."

The Priory Group has until 14 January 2025 to respond to Mr Long’s report, which must contain details of action taken or proposed to be taken, or an explanation of why no action is proposed.

The report has also been sent to Mr Ince’s family, Sabden and Whalley Medical Group, and the Care Quality Commission (CQC).