Coroner says care integration failings contributed to death

The coroner’s report raised concerns that there remained “a risk that future deaths could arise” in part due to a lack of a “joined up process” between services at County Durham and Darlington and Tees, Esk and Wear Valleys Foundation Trusts.

The “prevention of future deaths” report, published on 30 July, concerned the case of Andrew Naylor.

Mr Naylor, 37, died from acute cardiorespiratory failure and the depressant effects of alcohol after being discharged from the University Hospital of North Durham, run by CDDFT, on 10 October 2022.

He had been receiving treatment for a drug overdose, which included the administration of medication to treat his withdrawal from alcohol which was referenced in his medical cause of death.

Coroner Janine Richards said the lack of a joined-up process between the two trusts made it difficult for staff to ensure that “crucial information relevant to risk” was shared appropriately.

The report said the absence of protocol meant that “no full consideration” was given to the safety of Mr Naylor’s discharge, given that he was an alcoholic likely to drink and/or take drugs after leaving hospital.

The acute and mental health teams also did not consider contacting the deceased’s family or friends, which may have provided an “essential safety” net to Mr Naylor, who was homeless after being evicted from his supported accommodation, it added.

“Poor communication between the various agencies involved led to a failure to ensure a robust safety plan was in place,” the report said. “These cumulative failures contributed more than minimally to the death.”

The coroner concluded that, although both trusts indicated they were addressing the concerns raised in the PFD report: “I consider that at the time of the conclusion of this inquest, there remains a risk that future deaths could arise.”

The report follows both trusts having recently come under scrutiny for care failings.

TEWV was fined £200,000 by a magistrate in April after admitting to breaching regulation 12 of the Health and Social Care Act following the death of two patients under its care.

Meanwhile, a separate PFD report published in February said a newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department at the University Hospital of North Durham, as reported by HSJ in February.

In statements, both trusts sent their condolences to Mr Naylor’s family and said they were taking concerns regarding his care seriously and would address them transparently.

CDDFT said it had identified “areas for improvement” and would review its policies to ensure it was providing the “safest and most compassionate care to our patients”.

Beverley Murphy, the chief nurse at TEWV, said the trust would work in partnership with CDDFT to act on the inquest’s findings and was “committed to making improvements and providing the best care possible”.