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An inquest into the early and preventable death of Richard Handley, a young man who had Down's syndrome and suffered lifelong constipation, has found "gross [and] very significant failures" at almost every stage of his care.

The coroner, Peter Dean, criticised Mr Handley's care provider, GP practice, psychiatrist, social workers and staff at Ipswich hospital when he recorded a narrative verdict at Ipswich coroners court. The multiple omissions of care, he said, created an "extreme and tragic situation" that led to Mr Handley's death from constipation, a "condition that one is not expected to die of".

Aged just 33, Mr Handley died suddenly in Ipswich hospital in November 2012 after a heart attack caused by inhaling his own liquid faeces, vomited up because his bowel was severely obstructed by faecal impaction. His abdomen was, one doctor noted, the size of that of a woman who was 40 weeks' pregnant.

The coroner made a finding of gross failure in the actions of Ipswich hospital. The inquest heard that the hospital did not respond appropriately to Mr Handley's increased Modified Early Warning Score (Mews), designed to flag any deteriorating changes in a patient's condition.

Changes to Mr Handley's diet and the decreased monitoring of his bowel movements at his care home also contributed to his worsening constipation and ultimately led to his death, law firm Hodge Jones & Allen said.

The coroner criticised Bonds Meadow, a care home where Mr Handley lived from 1999. Bonds Meadow deregistered and became a supported living facility in 2010. That transition, he said, led to "significant changes" in Mr Handley's care.

The court heard that during Bonds Meadow's transition to a supported living facility, and unknown to his family, Mr Handley was taken off his strict diet. The court heard that careful monitoring of his health was downgraded or stopped, and his medication was changed to one with a known side-effect of constipation.

In evidence heard by the coroner, Mr Handley's key worker admitted he did not know he had the chronic bowel condition that would go on to kill him.

In the days leading up to his death, the coroner stated that there were many opportunities to save Mr Handley. Instead, the court heard evidence that he was failed by everyone responsible for his care.

The coroner said there were "gross failures" on the part of Ipswich hospital after Mr Handley was admitted days before his death. "The evidence we heard was that [Richard] still should have survived when he was attended with appropriate management," said the coroner. "[But] potentially life-saving treatment that should have occurred was missed ... that could have been conducted before Richard's condition worsened and his death from complications of the condition occurred."

The inquest heard that two days before Mr Handley died in 2012, medics removed 10kg of faeces from his bowels. That turned out to be just a small amount of the total in his body: the postmortem revealed that much more had become impacted in his bowel.

After the operation - while receiving what the hospital has admitted during the inquest was inadequate care - Mr Handley vomited up, then inhaled, liquid faeces. He had a heart attack from which he never regained consciousness. He died shortly afterwards.

Mr Handley's mother, Sheila, said: "Given the evidence we've heard in court, and the gross failures and missed opportunities noted, we are profoundly disappointed that the coroner felt unable to make a finding of neglect. The coroner did, however, recognise that without our diligence and persistence, many of the reviews into Richard's death would not have occurred and the inquest would not have been able to explore the extent of the failings in his care."

His sister, Emily, a senior clinical psychologist employed in a mental health service for people with learning disabilities, agreed. "Richard died an appalling death. It is difficult and harrowing to imagine how much pain and discomfort he must have been in, for quite some time," she told the Guardian.

The coroner said he was unable to record a finding of neglect as the cause of Mr Handley's death because "it's difficult to aggregate smaller failures by different agencies at different times to make one gross failure; there were undoubtedly failures at different times. What is significant is the fact that different agencies involved in Richard's care have undoubtedly worked hard to learn lessons from the circumstances of Richard's tragic death," he added.

Sheila Handley said: "Richard was wholly reliant on health and social care services to exist, and now he doesn't."
Topics

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'Gross failure' in man's care led to death from constipation

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An inquest into the early and preventable death of Richard Handley, a young man who had Down's syndrome and suffered lifelong constipation, has found "gross [and] very significant failures" at almost every stage of his care.

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Have a healthy diet in pregnancy - NHS.UK

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Find out how to eat a healthy diet in pregnancy, including plenty of fruit and vegetables, and cutting down on sugar and saturated fat.

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Take care of your mind

Looking after your mind is just as important as looking after your body, but it can be easily overlooked.

Every Mind Matters has lots of expert advice and practical tips to help you stay on top of your mental wellbeing.

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Take steps to improve your health. Lose weight, boost your mood, get active and quit smoking with Better Health. Try our free NHS tools and tips to get you started.

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SCIE - preventing abuse

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Training and consultancy services and resources to help safeguarding adults

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290318 policies practices and safeguarding.docx

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soham and safeguarding for students.docx

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safeguarding policy from a care home

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Nursing and midwifery council's code of practice

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No Secrets

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Manchester safeguarding adults board policies and procedures

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A national response to Winterbourne View Hospital.pdf

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winterbourne view department of health report

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winterbourne view dept health final report.pdf

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summary of Gemma Hayter's murder and serious case review

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Summary of work in response to Gemma Hayter Serious Case Review

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Gemma Hayer Serious Case Review

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Report of the Mid Staffordshire NHS Foundation Trust.pdf

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The worst scandal in the history of the NHS

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Mid Staffordshire NHS Foundation Trust Public Inquiry

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Safeguarding Adults Lessons from the murder of Steven Hoskin

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Safeguarding Adults Lessons from the murder of Steven Hoskin

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steven hoskin serious case review

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stephen hoskin scr executive summary.pdf

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The successes achieved and barriers encountered in delivering the Steven Hoskin Serious Case Review action plans, Feb 2009

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Steven Hoskin case- 5 years on

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Powerpoint on multi-agency working- including case studies (winterbourne and Mid-Staffordshire NHS Trust)

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delayed discharge/trafers of care and multi-disciplinary teams

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delayed discharge/trafers of care and multi-disciplinary teams

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Delayed transfers of care and multi disc.docx

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multi-disciplibary teams- see slides 16, 18, 28 and 32

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multi-disciplibary teams- see slides 16, 18, 28 and 32

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Foyer self referral application form.pdf

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report on issues relating to the care crisis (eg limited access to home care etc)

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report on issues relating to the care crisis (eg limited access to home care etc)

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Person-centred planning in social care.pdf

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person-centred care- appropriate forms of communication

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person-centred care- appropriate forms of communication

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What is person-centred care and why is it important?

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What is person-centred care and why is it important?

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170518 nhs confidentiality and immigration.docx

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240518 recap exercise (principles of person-centred care)

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240518 recap exercise (principles of person-centred care)

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Take care of your mind

Looking after your mind is just as important as looking after your body, but it can be easily overlooked.

Every Mind Matters has lots of expert advice and practical tips to help you stay on top of your mental wellbeing.

# data[].attributes.attachment_link.description
Take steps to improve your health. Lose weight, boost your mood, get active and quit smoking with Better Health. Try our free NHS tools and tips to get you started.

# data[].attributes.attachment_link.readable_text
An inquest into the early and preventable death of Richard Handley, a young man who had Down's syndrome and suffered lifelong constipation, has found "gross [and] very significant failures" at almost every stage of his care.

The coroner, Peter Dean, criticised Mr Handley's care provider, GP practice, psychiatrist, social workers and staff at Ipswich hospital when he recorded a narrative verdict at Ipswich coroners court. The multiple omissions of care, he said, created an "extreme and tragic situation" that led to Mr Handley's death from constipation, a "condition that one is not expected to die of".

Aged just 33, Mr Handley died suddenly in Ipswich hospital in November 2012 after a heart attack caused by inhaling his own liquid faeces, vomited up because his bowel was severely obstructed by faecal impaction. His abdomen was, one doctor noted, the size of that of a woman who was 40 weeks' pregnant.

The coroner made a finding of gross failure in the actions of Ipswich hospital. The inquest heard that the hospital did not respond appropriately to Mr Handley's increased Modified Early Warning Score (Mews), designed to flag any deteriorating changes in a patient's condition.

Changes to Mr Handley's diet and the decreased monitoring of his bowel movements at his care home also contributed to his worsening constipation and ultimately led to his death, law firm Hodge Jones & Allen said.

The coroner criticised Bonds Meadow, a care home where Mr Handley lived from 1999. Bonds Meadow deregistered and became a supported living facility in 2010. That transition, he said, led to "significant changes" in Mr Handley's care.

The court heard that during Bonds Meadow's transition to a supported living facility, and unknown to his family, Mr Handley was taken off his strict diet. The court heard that careful monitoring of his health was downgraded or stopped, and his medication was changed to one with a known side-effect of constipation.

In evidence heard by the coroner, Mr Handley's key worker admitted he did not know he had the chronic bowel condition that would go on to kill him.

In the days leading up to his death, the coroner stated that there were many opportunities to save Mr Handley. Instead, the court heard evidence that he was failed by everyone responsible for his care.

The coroner said there were "gross failures" on the part of Ipswich hospital after Mr Handley was admitted days before his death. "The evidence we heard was that [Richard] still should have survived when he was attended with appropriate management," said the coroner. "[But] potentially life-saving treatment that should have occurred was missed ... that could have been conducted before Richard's condition worsened and his death from complications of the condition occurred."

The inquest heard that two days before Mr Handley died in 2012, medics removed 10kg of faeces from his bowels. That turned out to be just a small amount of the total in his body: the postmortem revealed that much more had become impacted in his bowel.

After the operation - while receiving what the hospital has admitted during the inquest was inadequate care - Mr Handley vomited up, then inhaled, liquid faeces. He had a heart attack from which he never regained consciousness. He died shortly afterwards.

Mr Handley's mother, Sheila, said: "Given the evidence we've heard in court, and the gross failures and missed opportunities noted, we are profoundly disappointed that the coroner felt unable to make a finding of neglect. The coroner did, however, recognise that without our diligence and persistence, many of the reviews into Richard's death would not have occurred and the inquest would not have been able to explore the extent of the failings in his care."

His sister, Emily, a senior clinical psychologist employed in a mental health service for people with learning disabilities, agreed. "Richard died an appalling death. It is difficult and harrowing to imagine how much pain and discomfort he must have been in, for quite some time," she told the Guardian.

The coroner said he was unable to record a finding of neglect as the cause of Mr Handley's death because "it's difficult to aggregate smaller failures by different agencies at different times to make one gross failure; there were undoubtedly failures at different times. What is significant is the fact that different agencies involved in Richard's care have undoubtedly worked hard to learn lessons from the circumstances of Richard's tragic death," he added.

Sheila Handley said: "Richard was wholly reliant on health and social care services to exist, and now he doesn't."
Topics

# data[].attributes.attachment_link.title
'Gross failure' in man's care led to death from constipation

# data[].attributes.attachment_link.description
An inquest into the early and preventable death of Richard Handley, a young man who had Down's syndrome and suffered lifelong constipation, has found "gross [and] very significant failures" at almost every stage of his care.

# data[].attributes.attachment_link.title
be clear on cancer evaluation results 2014.pdf

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statistics on the effectiveness of public health campaigns

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statistics on the effectiveness of public health campaigns

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statistics on the effectiveness of public health campaigns.docx

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information on measles outbreak of 2012-13 and general public health articles

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information on measles outbreak of 2012-13 and general public health articles

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220618 Public health strategies exercise.docx

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GCE A Level History_Poverty watermarked pdf 21-07-2016_Ch1.pdf

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healthy life expectancy (office of national statistics)

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healthy life expectancy (office of national statistics)

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disability free life expectancy  (office of national statistics)

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disability free life expectancy  (office of national statistics)

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health information from the office of national statistics

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health information from the office of national statistics

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Unit 12 New Assignment Brief Approved.docx