A report into the death of a man with Down’s syndrome at Newham University Hospital has revealed that he was left to live with a serious and life-threatening infection, which later became gangrenous, despite 27 healthcare professionals knowing about the infection and failing to provide appropriate support.
The man, named as Paul in the safeguarding review, had no support from family, a support worker or an advocate who would argue for his needs, said the report, and lived alone in a one-bedroom flat where he was supposed to be supported at all times by a carer, but on at least one occasion this carer did not show up for their shift per the report.
It was discovered by doctors more than six months before his death that Paul had a small blister which they believed was caused by a yeast infection, friction burns or pressure sores, and later doctors discovered that he was suffering from skin infections and MRSA – but these issues were never reported to the learning disability team who supported him.
The report states that Paul’s infection escalated so severely that he became unable to leave his bed, at which point paramedics were called. The report states that paramedics “noticed a smell in Paul’s flat, consistent with necrosis [or] dying body tissue.” It continued: “It would be an expectation that care staff and managers would recognise and act upon this. This did not happen.”
Paul was immediately placed in intensive care, where a tube was inserted down his throat four times, resulting in the removal of his ability to swallow solid food, and also underwent two operations which were intended to remove the gangrene which was threatening his life. Despite this, Paul died on May 30, 2015, as a result of respiratory failure and sepsis.
The report noted: “Paul suffered in pain for more than six months. He experienced indignity and discomfort in hospital despite efforts by many professionals who recognised this and tried to work together to address it.
“He never recovered from the medical problems arising from the gangrene that developed at his home. This was the reason for his hospital admission and could have been prevented if there had been more effective collaboration between professions.”
In a statement, the Down’s Syndrome Society, who were “shocked and appalled” by the revelations surrounding Paul’s death, said: “This distressing case represents failings at a very basic level.
“The care provider failed to offer even the most basic standards of care while also failing to properly train staff to meet the specific needs of a vulnerable individual.
“Paul was not given the support he needed. As a result of this neglect he died from complications of a condition which should have been preventable. Sadly, Paul’s story is not unique and we are aware of a number of cases where individuals with Down’s syndrome have died prematurely where their care has fallen short of the standards they have a right to expect.”Get your copy of UNITE Magazine