Coroner slams Essex health trust for care investigation failure

A coroner has raised concerns a disabled patient was not given the most basic nursing care

A coroner has criticised a hospital trust for failures investigating concerns for a disabled patient.

Ronald Ashdown, 55, was discharged from a care home to Basildon Hospital in July 2021 where staff noticed skin issues indicative of him not being washed for days.

There had been a "serious failure in the provision of the most basic of nursing care," the coroner said.

Patient care is a priority, Mid and South Essex NHS Foundation Trust said.

Mr Ashdown had severe disabilities caused by a hypoxic brain injury in 2013 and died in hospital on 15 August 2021 from complications of his condition.

He had previously been admitted to the hospital in July and, upon discharge, staff at The Coach House nursing home in Grays found flaking skin on parts of his body, as well as dried faecal matter.

Essex coroner Sean Horstead said despite the care failings not directly impacting Mr Ashdown's cause of death, he was concerned similar failings could lead to fatal infections for others.

There was a "significantly flawed" investigation by the trust, he said.

Mid and South Essex NHS Trust, which runs Basildon Hospital was criticised for a "lack of professionalism" and "significant flaws" during an internal investigation

The trust investigated after Mr Ashdown's daughter and the care home presented photos and their concerns, but denied any issues with his care, citing nursing notes that documented Mr Ashdown had been washed every day.

Nursing records were "demonstrably untrue", the corner said in a Prevention of Future Deaths Report.

It was only at the inquest that the trust conceded the photo evidence showed he had not been washed "for several days", the coroner said.

He said witnesses for the trust accepted that, if not for the inquest, denial of failings "would have remained unchallenged".

It would also have perpetuated a "false record of the basic nursing care" to Mr Ashdown who was "highly vulnerable and dependent", Mr Horstead said.

'Grave concern'

He said evidence suggested the issue went beyond one or two members of staff and was not picked up on by senior nurses.

Mr Horstead also cited a "lack of professionalism" shown by the trust investigation as a "cause of grave concern".

Issues with the internal inquiry impacted other safeguarding investigations by Thurrock Safeguarding and a wider investigation - of which Mr Ashdown's case was one of three being looked at, Mr Horstead said.

These other investigations were undermined and would need a review, the coroner added.

Denise Townsend, deputy chief nursing officer for the trust, said: "Providing the best possible patient care is our absolute priority, but we are not able to discuss the particulars of this case whilst the investigation is still ongoing."

A spokesperson for the Care Quality Commission (CQC), the healthcare regulator, said it was liaising with the trust regarding the concerns raised in the coroner's report.