NHS trust ‘neglected’ mental health patient

North East London NHS Foundation Trust (NELFT)

Warnings were ignored in care of mental health patient prior to his death, reports Victoria Munro, Local Democracy Reporter

A 35-year-old man died from pneumonia in his Chingford flat after being neglected by the NHS trust in charge of his care, an inquest found.

Paul Tufton, who was severely schizophrenic, deteriorated to the point where he could not walk or even sit up, rapidly losing so much weight his clothes size went from XXL to medium.

His cousin, a former Pentonville prison officer, told Walthamstow Coroner’s Court it would have been illegal to leave a prisoner in a cell as disgusting and soiled as Paul’s flat.

The court also heard from Paul’s carer – only given two hours a day to bathe him, give him medication and prepare all his meals – who said she sometimes used her own money to buy his food.

East London coroner Nadia Persaud last month ruled that Paul died on 7th July 2019 from “natural causes contributed to by neglect” after North East London Foundation Trust (NELFT) failed to give him “basic medical attention”.

Paul’s sister Jo Stickley said that, at a meeting just weeks before he died, she told psychiatry specialist Dr Othmane El Mezoued “in the clearest terms” how worried the family was. Speaking to Dr El Mezoued, she said: “My father told you that if we waited for any more assessments ‘we will be standing around a corpse’.

“You assured me that you were going to write an urgent report and escalate our concerns and I believed you, but you did none of those things, none of them.”

Grant Tufton described being horrified by the condition of his cousin’s Chingford flat, where he was being housed by Waltham Forest Council because of his severe vulnerability. 

He told the court: “It would have been illegal for a convicted criminal to be left on a mattress like the one Paul had to lie on. No prisoner would ever be left in a cell with faeces on the floor.

“He was living in darkness as the light did not work and he was incapable of going out. He physically did not have anything to live for.

“I was very concerned that, despite the fact Paul had professional carers, no-one seemed to have noticed this.”

Paul’s parents Dave and Marilyn Tufton live in Shrewsbury and travelled to see him in June 2019, a month before his death. They said: “The slightly overweight, physically fit man we knew was reduced to a gaunt-looking, severely underweight shadow of his former self.

“By the end of June, his condition seemed to be getting worse. He was wet each time we went round, sometimes extremely hungry, and unable to reach food left for him.

“Our concerns expressed to those caring for Paul were never addressed.”

Paul’s care was paid for by the council and provided by Livingstone Health Care, which is rated by the Care Quality Commission as ‘requires improvement’. One employee, Matilda Boakye, was responsible for all of his personal care and saw him for an hour every morning and half-an-hour every afternoon and evening.

Matilda said: “Sometimes I spent more than my time, especially the lunch call. I told my line manager ‘I can’t do this work alone’. I did complain once that the place was really filthy. I talked to my manager and he said it was not our concern.

“I complained to my manager two times about his food but I do not know whether he followed up. I did my best.”

The court heard Matilda had almost no experience in care work when she first started caring for Paul and would go out several times a week to get him food, sometimes using her own money. She had no nutritional training at the time and bought him what he said he wanted to eat, which was Weetabix and pizza.

After hearing two days of evidence the coroner concluded: “If Paul was living in a clean environment with his nutrition, continence and hygiene needs met, it’s likely his death would have been avoided.

“Had he received the attention and action he required, he would not have been living in those conditions.”

The court heard Paul’s care co-ordinator at NELFT, who left the trust in November last year, appeared to have failed to carry out several vital tasks, such as requesting health assessments. He was not present at the inquest because he had left the country, but a NELFT clinical lead said the trust was not aware of any disciplinary action taken against the former employee before he left the trust.

NELFT objected to the coroner’s ruling that it had neglected Paul, with a lawyer arguing there was “no evidence of Mr Tufton suffered gross failures” in their care. Coroner Nina Persaud disagreed but recognised “a number of steps have been taken to improve a number of areas” at the trust since his death.