Jury conclude that Andrew Clark died due to neglect by mental health hospital

On 26 February 2022, Andrew Clark, a 56-year-old detained patient died from diabetic ketoacidosis at St Peter’s Hospital in Surrey following a sustained period of mismanagement of his diabetes by healthcare staff at Cygnet Lodge in Woking where he was detained. 

Andrew was one of 5 children.  He was brought up in Bridgend.  He was diagnosed with schizophrenia and schizo-affective disorder. Andrew had lived with Type 2 diabetes since 2004 without major incident. He lacked capacity because of his mental ill-health and was reliant on healthcare staff to manage his diabetes. 

In February 2022, when Andrew was a patient at Cygnet Hospital in Surrey, the Jury found that there were “repeated gross failings” to manage Andrew’s diabetes appropriately. His blood sugar was not monitored regularly in accordance with the care plan.  His ketones were not checked when his blood sugar levels exceeded safe levels.  Staff failed to notice that Andrew had lost 5kg in the space of two weeks, a well-known warning marker for severe hyperglycaemia (high blood sugar levels). Nursing staff failed to recognise or effectively escalate concerns regarding the deterioration in Andrew’s health to the medical team.  The medical team did not address concerns that were raised with them. No specialist help was requested when it was sorely needed.  The multi-disciplinary team did not function effectively to oversee care and ward managers did not pick up on obvious gaps in the patient records. 

The Jury found that, from the evening of 24 February 2022, Andrew was overtly unwell and needed to be sent to hospital for urgent treatment.  He had become increasingly confused, unsteady, was experiencing rapid breathing, and his blood glucose levels were HI (i.e. off the charts).  

The Jury heard that, by about 9am on 26 February, all staff agreed that Andrew needed to be transferred to hospital immediately. But this did not happen for a further 5 hours.  A member of nursing staff gave evidence that the responsible clinician (a consultant psychiatrist) had been requested to attend but refused.  Andrew was eventually transferred to St Peter’s Hospital. Despite their best efforts, unfortunately they could not save his life. He died at approximately 7pm on 26 February. 

In addition, the Jury concluded that there was a “systemic lack of accountability, awareness, continuity, and synergy and communications across all staffing levels. Culturally, there was a heavy reliance on assumptions”. 

Following evidence of significant management failures within the organisation, the Coroner has indicated that she will make a Preventing Future Deaths report to Cygnet. 

Furthermore, of wider public interest, Cygnet outsourced responsibility for conducting a Serious Incident review into Andrew’s death to a private consultancy called Delphi Care Solutions.  The Coroner and independent experts in this case expressed significant concerns regarding the quality of their report and the recommendations which emerged from it. The Coroner indicated that this was part of a wider outsourcing trend in relation to serious incident reports and stated that she was considering writing reports to a number of organisations, including NHS England (who have oversight of the Serious Incident reporting framework and its successor Patient Safety Incident Response Framework), the Health Services Safety Investigations Body (HSSIB), Care Quality Commission, and Delphi Care Solutions.  The Family are hopeful that this action will ensure that lessons are learned regarding avoidable deaths of patients in hospital. 

More coverage of the case can be found at the Independent and on Inquest’s website.   

The Family were represented by Leanne Devine of Scott Moncrieff Solicitors, and Frederick Powell of Doughty Street Chambers.  For more information about Frederick, contact our Senior Inquests and Inquiries Practice Manager, Melvin Warner.