Matthew Hill helps family obtain neglect finding at inquest into respite care death.

Emily Bushaway was a 21 year old woman with Niemann-Pick Disease, a rare genetic condition that left her wholly dependent on others for all of her needs. She received excellent care from her family and a team of trained, specialist nurses at her home. She also received respite care at Helen and Douglas House, a charitable care home in Oxford.

In May 2016 Emily attended Helen and Douglas House for a five-day stay. Since her last visit her care needs had changed as she now required invasive ventilation administered through her tracheotomy. The equipment she used included a ‘whisper valve’, which allowed her to exhale. Her family informed Helen and Douglas House in advance of her need for ventilation and no concerns were raised.

On the last day of her stay, a nurse attempted to change part of Emily’s ventilation equipment. In doing so, she inadvertently removed and discarded part of the whisper valve. The mistake was not realised and no check was done of the equipment. Over the following hour or so, Emily deteriorated. An ambulance was called, but no further steps were taken to provide basic life support. It was not until Emily’s father and home nurse arrived that the missing part of the whisper valve was identified and oxygen provided. Sadly it was too late as Emily entered cardiac arrest and died shortly afterwards.

The Senior Coroner for Oxfordshire, Darren Salter, returned a narrative determination, in which he found that the death was contributed to by neglect. He had heard that many of the nurses at Helen and Douglas House, including the nurse who discarded part of the whisper valve, had received no training on the ventilation system used by Emily. They had not seen a whisper valve before and did not know what it was for. The original care plan, written by a student nurse, failed to highlight the critical importance of the valve and the risk of suffocation if it was incorrectly assembled.

A subsequent care plan was written by a nurse who researched the whisper valve on Google and had not been shown how to dismantle and assemble it. Emily’s family had invited Helen and Douglas House to contact them or the nursing team at any time if they had any questions: no-one did so. No written records were kept of the core competencies of the nursing staff so at to inform their allocation to specific patients. An incident in January 2016 in which a ventilator was incorrectly assembled without a whisper valve at Helen and Douglas House did not lead to a serious incident report, or indeed any further discussion or training.

Matthew represented Emily’s family. He was instructed by Tim Deeming and Slater and Gordon.