Lucy McCann appeared on behalf of the family of Sophie Towle, who died at the age of 22 after suffering a cardiac arrest from a pulmonary thromboembolus secondary to a DVT in her left leg.
The three-week Article 2 inquest heard evidence from 30 witnesses including an expert intensivist.
The facts
The jury heard that Sophie had a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and ADHD. She had a complex history of self-harm, and was known to adult mental health services since 13 March 2021.
On 05 December 2024, Sophie was admitted to Brodsworth Ward under the care of Rotherham Doncaster and South Humber NHS Foundation Trust (RDASH) and was detained under s.3 of the Mental Health Act 1983. She remained there for approximately five months, and her family noted a gradual improvement in her mental health and overall presentation during her stay.
On 25 April 2024, Sophie was transferred to Fir Ward under the care of Nottinghamshire Healthcare NHS Foundation Trust (NHFT). Neither Sophie nor her family had been consulted about the decision to transfer her to Nottinghamshire prior to the transfer. The Jury found that the transfer destabilised Sophie and determined that there was “no clinical rationale” for the transfer itself. The Jury agreed with the admission made by RDASH during the proceedings that communication to Sophie, her family and her care co-ordinator in respect of the transfer was poor.
Following the transfer to Fir Ward, Sophie was initially placed on 1:1 observation for 24 hours a day. The Jury found that no body mapping, weight management planning or wound care planning took place upon admission.
On 12 May 2024, Sophie engaged in a serious act of self-harm by inserting a foreign object deep into a chronic leg wound. At the time Sophie was on 1:1 constant eyesight observations, which the Jury found were inadequate and not in line with the Trust’s policy. The Jury concluded that this amounted to neglect. Sophie was sent to King’s Mill Hospital where the Orthopaedic Department decided the object would not be removed and Sophie was discharged, returning back to Fir Ward in a wheelchair.
The following day, a decision was made by staff to remove Sophie’s 1:1 observations and replace this with observations every 10-minutes, which was against both Sophie and her family’s wishes. The Jury found that there was a lack of clarity / purpose for reducing observations, given Sophie’s presentation at the time.
From 12 – 27 May 2024, Sophie was in an increasing amount of pain as a result of the foreign object in her leg, and her mobility significantly reduced. Staff on Fir Ward were increasingly concerned about the risk of infection and contacted King’s Mill Hospital on a number of occasions to inform the clinicians of their concerns. Without physically re-assessing Sophie, staff at the Hospital maintained their decision not to remove the foreign object. The Jury found that whilst the initial rationale not to operate was adequate, there was a lack of curiosity from the Orthopaedic team relating to Sophie’s mobility and found the lack of any re-assessment to be inadequate.
On 27 May 2024, Sophie suffered a cardiac arrest from which she did not recover. Sophie sadly died as a result of a large Pulmonary Thromboembolus due to underlying DVT of the leg veins.
During the course of the proceedings, it was admitted by NHFT that whilst on Fir Ward, there was a failure to complete further assessments of Sophie’s Venous Thromboembolism (VTE) risk, either periodically or when circumstances changed to increase her risk, such as reduced mobility and/or retention of the foreign object in Sophie’s leg. NHFT accepted that there was no formalised plan to manage Sophie’s obesity or support the monitoring of Sophie’s leg wound and admitted that physical health checks were not consistently obtained in accordance with her care plan.
In turn, it was accepted by NHFT that in failing to manage Sophie’s VTE risk after the foreign object was inserted into her leg, this probably more than minimally contributed to her death. The Jury ultimately agreed with this admission.
In addition to the findings outlined above and the rider of neglect due to the inadequacy of the observations, the jury also found failures related to risk management, information sharing, staff levels and experience.
Assistant Coroner Alexandra Pountney issued a Regulation 28 report to Nottinghamshire Healthcare NHS Foundation Trust and Sherwood Forest Hospitals NHS Foundation Trust (see here).
The case was featured in national and local press.
Lucy was instructed by Kelly Darlington, and assisted by Cliona Carey, of Farleys Solicitors (see statement here).
