AN ANDOVER man was found dead in a frosty car park after hospice staff took a ‘double break’ and failed to spot he was missing.
Michael Curtis, 76, from Andover, had a number of medical conditions and was suffering from blood cancer. In March last year, his condition began to deteriorate, with him showing signs of confusion and unsteadiness linked to a pre-existing heart condition.
He was admitted to the Countess of Brecknock Hospice in the grounds of Andover Hospital for respite care.
On March 17 2020, Michael woke frequently in the night and was found out of bed on more than one occasion. He remained unsettled and staff were told to ‘keep an eye on him.’
The following morning, a passer-by found Michael dead outside near to the hospital car park.
Following his death, Michael’s wife Penny, 75, instructed medical experts at Irwin Mitchell to investigate her husband’s care under the Hampshire Hospitals NHS Foundation Trust.
An investigation report published by the NHS found Michael was left unchecked between 4.30am and 7am, with one member of staff on a break from 4.20am to 6.20am which was double the allowed one hour and “would have increased the pressure/workload for the whole team.”
Michael was found around 170 metres from his exit route from the hospice. He had left the first floor, moved down two flights of stairs and into a section of the hospice that was still under construction. Michael then walked through the exit door and into the builder’s compound.
CCTV footage recorded Michael’s entire journey and showed him moving from the builder’s compound through the unlocked gate and along the perimeter fencing. Michael then continued to walk up the road and into the car park. He finally made a turn that would lead him back to the hospice where he collapsed and was found by a passer-by.
In addition, Michael’s medication had not been administered at 6am as it should have been. The report states “had the nursing staff attempted to give this, they would have noticed the patient was missing earlier and looked for him at this time.” Furthermore, the next ward round “was due at 6.30am and not completed.”
It was reported that the fire door and stair gate that Michael left from was merely on a latch with no alarm system in place.
Hampshire Hospitals NHS Foundation Trust has since admitted a breach of duty.
It has accepted a failure to ensure Michael was “appropriately monitored and kept safe during his time at the hospice.”
The Trust’s report advised that the door at Countess of Brecknock Hospice should have been alarmed which would have alerted staff to Michael’s absence.
Joe Haley, the medical negligence specialist at Irwin Mitchell said: “The past year has been incredibly difficult for Michael’s family, particularly Penny who is still struggling with coming to terms with losing her husband so tragically.“Through our work we sadly come across many people left devastated following the death of a loved one. While nothing will ever make up for what’s happened or bring Michael back, we’re determined to support Penny and her family by providing them with the answers they deserve.“Meanwhile, the NHS report has identified some worrying issues and omissions in Michael’s care and we now urge that any recommendations are implemented as soon as possible to improve on patient safety.”
Recommendations made in the report included the introduction of hourly rounding alongside a process to ensure its completion, as well as a formal risk assessment as to whether the fire door should be fitted with an alarm and an investigation into the conduct of staff on shift overnight.
HHFT has been approached for comment.
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