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An NHS trust has been fined over a "catalog of failures" that saw a dementia patient flee hospital three times and die after hitting his head on concrete. Peter Mullis, who has advanced dementia, was discharged from Queen's Hospital in Burton upon Trent, Staffordshire, twice in the space of hours before the fatal incident on July 15, 2019. After running out of hospital, he jumped over a fence and fell onto a grass embankment, and the 77-year-old died of multiple traumatic injuries, prosecutor Ayman Khokhar said during a hearing at South Derbyshire Magistrates Court on Monday. in Derby.
University Hospitals of Derby and Burton (UHDB) NHS Trust, which runs the centre, has been fined £200,000 after pleading guilty to being a care provider who put a patient at significant risk of avoidable harm, during its first trial. penal.
Mr Khokhar, who filed a lawsuit on behalf of the Care Quality Commission, said Mr Mullis was taken to hospital after failing to respond at his skilled care home on July 14, 2019.
He was known to have a "propensity to run away from clinical settings" and had been described by health care staff as an "escape artist", having twice escaped from different wards in the hospital prior to the fatal incident.
Mr. Khokhar said: “Around 2 pm (July 15), the deceased left the service for the third time.
“Two nurses ran after him. Unfortunately, seeing the nurses running towards him, the deceased decides to run down the corridor to the exit.
“Once outside, the deceased stopped running. He threatened to hit the staff if they came near him.
“Unfortunately the deceased continued with metal barriers approximately one meter high, the nurse asked him to return.
"In response, he yelled 'don't come near or I'll hurt you.' He then jumped over a barrier that was on top of a sloping embankment."
I feel like I was deprived of rediscovering my father. It was basic protection.
"He yelled 'you're not going to stop me' and started down the slope.
“As he neared the bottom of the incline, he lost his balance and fell to the pavement. This produced an audible crack.
Mr Mullis, a Burton horticulturist, was airlifted to Royal Stoke University Hospital but died later that day.
Khokhar said the CQC believed there was a "catalog of failures" that contributed to Mullis' "preventable death", including insufficient staff training and limited policies on how to deal with missing patient complaints.
In a statement read out by Khokhar, Mullis's daughter, Selina Kendrick, said "inadequate levels of training" contributed to her father's death.
She said: "It was a complete shock. We had plans and how quickly they changed is unbearable.
“I feel like I was deprived of rediscovering my father.
"It was basic protection."
I have great sympathy for the valuable and hard-working staff of the Trust, who I believe have done their best to deal with the difficulties raised by Mr Mullis.
Eleanor Sanderson, mitigating, said that the care provided to Mr Mullis was "not a general failure" and that there was little likelihood of death in the circumstances, but acknowledged that policies had not been followed and steps had been taken to ensure that such an incident did not occur. it will happen again.
She added: “It is correct that at the heart of the guilty plea is a failure to follow the correct procedure established by policy.
“Those who cared for him tried to assess him and contribute to his needs.
"Confidence is understood to mean that the practice of undertaking (risk assessments) was not sufficiently integrated."
Handing down the sentence, which could have been an unlimited fine, District Judge Jonathan Taaffe said: "I have considerable sympathy for the valuable and hard-working staff of the trust, who I believe have done everything possible to deal with the difficulties raised for Mr Mullis and his advanced dementia in the cramped situation of the hospital.
“The robust procedures that were in place were not followed enough.
“I also note that the trust is a state-funded agency that does not operate for profit. Any fine will divert funds from frontline services.
In addition to the fine, the trust was also ordered to pay costs of £16,483.88 and a victim penalty surcharge of £181.
After the hearing, Garry Marsh, the Trust's chief nursing officer, said: "We are very sorry for what happened to Mr Mullis, and our deepest condolences continue to go out to his family."
"Mr. Mullis was supervised during his time in our care, but it is clear that improvements were needed in the way that some of our policies, there to keep people like Mr. Mullis safe, were put into practice and we accepted fully the conclusions of the CQC.
“Since that sad incident in 2018, we have created a dedicated Mental Ability Act Education Team to better support and train our staff, and introduced a new audit process to track compliance with best practices.
"We remain absolutely committed to doing even better to ensure that we provide the safest care and treatment to all patients in our care."
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