Stephen Dulling
PFD Report
All Responded
Ref: 2024-0549
All 2 responses received
· Deadline: 9 Dec 2024
Coroner's Concerns (AI summary)
The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.
View full coroner's concerns
In respect of Tees Esk and Wear Valley NHS Foundation Trust -
1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical OFFICIAL advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others. In respect of York & Scarborough Teaching Hospitals NHS Foundation Trust –
4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings – a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity; b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above; c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment; d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids; e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking; f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical OFFICIAL advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others. In respect of York & Scarborough Teaching Hospitals NHS Foundation Trust –
4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings – a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity; b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above; c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment; d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids; e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking; f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
Responses
Noted
The Trust defends its advice to contact the police due to concerns about violence and aggression. Learning from this incident will be shared at various Trust meetings. (AI summary)
The Trust defends its advice to contact the police due to concerns about violence and aggression. Learning from this incident will be shared at various Trust meetings. (AI summary)
View full response
6 December 2024
Private and Confidential Catherine Cundy Area Coroner for North Yorkshire and York By email:
Inquest into the death of Stephen Dulling I am writing to you in response to the Report to Prevent Future Deaths (PFD), dated 14 October 2024, following the sad death of Mr Dulling. I note that the PFD is directed to both Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and York and Scarborough Teaching Hospitals NHS Foundation Trust. This response is provided on behalf of TEWV. I understand that your concern in relation to TEWV is the management of a phone call to the All Age Crisis Line and the advice which was provided to contact the Police. The Crisis Team are not an emergency service and when there is felt to be an immediate and significant risk, the correct advice is for the emergency services to be contacted, which depending upon the nature of the call will either be done by the person contacting emergency services themselves or the Crisis Team agreeing to contact on their behalf. This will then result in a decision being made by the emergency services as to whether there will be a response from the Police or Ambulance Service. In this case, due to the concerns of violence and aggression, the correct advice was provided for the Police to be called. This is because the Police can provide an urgent response and have additional powers, such as the ability to enter a person's home, or in certain situations, take a person to a place of safety, such as a hospital for a Mental Health Act assessment, under S136 of the Mental Health Act. Had the advice been followed and the Police contacted, the Police would have provided an emergency response in relation to the threat of violence, whilst liaising with the Crisis Team and any other services required, such as the ambulance service, to ensure that there was an appropriate assessment of Mr Dulling's mental state and risk, either via an assessment from the Crisis Team or through a Mental Health Act assessment.
Office of the Chief Executive West Park Hospital Edward Pease Way Darlington Co Durham DL2 2TS
I am sorry to hear that the role and rationale for contacting the Police was not clearly communicated to Mr Dulling's wife. The case will be presented at the Trust Urgent Care Board which takes place on the 23 January 2025. Learning from this incident will also be shared at the all the Trust's Specialty Clinical Networks meetings on 19 December 2024, 20 December 2024, 7 January 2025 and 22 January 2025 via the service development managers for adult mental health, mental health services for older people, child and adolescent mental health services and adult learning disabilities to highlight the importance of clear communication and the impact of it and to the Trustwide Organisational Learning Group on 5 December 2024. The meetings are attended by specialist practitioners, service development managers, consultant psychologists, associate medical and nursing directors from across the Trust, who will disseminate the learning. I hope that the above clarifies your concerns, but should you have any additional queries please do not hesitate to contact me.
Private and Confidential Catherine Cundy Area Coroner for North Yorkshire and York By email:
Inquest into the death of Stephen Dulling I am writing to you in response to the Report to Prevent Future Deaths (PFD), dated 14 October 2024, following the sad death of Mr Dulling. I note that the PFD is directed to both Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and York and Scarborough Teaching Hospitals NHS Foundation Trust. This response is provided on behalf of TEWV. I understand that your concern in relation to TEWV is the management of a phone call to the All Age Crisis Line and the advice which was provided to contact the Police. The Crisis Team are not an emergency service and when there is felt to be an immediate and significant risk, the correct advice is for the emergency services to be contacted, which depending upon the nature of the call will either be done by the person contacting emergency services themselves or the Crisis Team agreeing to contact on their behalf. This will then result in a decision being made by the emergency services as to whether there will be a response from the Police or Ambulance Service. In this case, due to the concerns of violence and aggression, the correct advice was provided for the Police to be called. This is because the Police can provide an urgent response and have additional powers, such as the ability to enter a person's home, or in certain situations, take a person to a place of safety, such as a hospital for a Mental Health Act assessment, under S136 of the Mental Health Act. Had the advice been followed and the Police contacted, the Police would have provided an emergency response in relation to the threat of violence, whilst liaising with the Crisis Team and any other services required, such as the ambulance service, to ensure that there was an appropriate assessment of Mr Dulling's mental state and risk, either via an assessment from the Crisis Team or through a Mental Health Act assessment.
Office of the Chief Executive West Park Hospital Edward Pease Way Darlington Co Durham DL2 2TS
I am sorry to hear that the role and rationale for contacting the Police was not clearly communicated to Mr Dulling's wife. The case will be presented at the Trust Urgent Care Board which takes place on the 23 January 2025. Learning from this incident will also be shared at the all the Trust's Specialty Clinical Networks meetings on 19 December 2024, 20 December 2024, 7 January 2025 and 22 January 2025 via the service development managers for adult mental health, mental health services for older people, child and adolescent mental health services and adult learning disabilities to highlight the importance of clear communication and the impact of it and to the Trustwide Organisational Learning Group on 5 December 2024. The meetings are attended by specialist practitioners, service development managers, consultant psychologists, associate medical and nursing directors from across the Trust, who will disseminate the learning. I hope that the above clarifies your concerns, but should you have any additional queries please do not hesitate to contact me.
Action Taken
The Trust updated its Food, Nutrition and Hydration Policy in November 2024 and is consolidating nutritional assessments into one section of the electronic nursing record. They have also revised incident management processes and implemented a new policy for post-incident debriefs. (AI summary)
The Trust updated its Food, Nutrition and Hydration Policy in November 2024 and is consolidating nutritional assessments into one section of the electronic nursing record. They have also revised incident management processes and implemented a new policy for post-incident debriefs. (AI summary)
View full response
Dear Madam Thank you for raising your concerns as a result of the inquest into the death of Mr Stephen Dulling, following his admission to York District Hospital. York & Scarborough Teaching Hospitals NHS Foundation Trust (the Trust) recognises the seriousness of these findings, and I write to outline the actions we are taking to address the lapses identified. These measures are intended to reduce the risk of recurrence and improve the quality and safety of care provided to our service users. Coroner’s concern:
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment
It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not detailed enough and that a food chart was not instigated/completed when it should have been. The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in November 2024. There are currently several assessments, relating to eating and drinking and nutrition, that nursing staff undertake when a patient is admitted. These assessments are not all located in the same place and not as intuitive as they could be. We recognise that this is
2 not optimal and are in the process of bringing these assessments together into one section of Nucleus (electronic digital nursing record) and this is due to go live in January 2025. We are confident that this will significantly reduce the risk of essential information being overlooked. The Trust recognises the previous poor compliance in this area, as identified in Mr Dulling’s case, and this is a focus of current quality improvement project work. The Trust has completed a Patient Safety Incident Investigation (PSII) cluster review of Speech and Language Therapy (SLT) and swallow related incidents. This was presented to the Trust’s Serious Incident Group in December 2024 with an associated action plan. The PSII identified themes around lack of or delayed referral to SLT as well as food and drink given to patients that is not the IDDSI (International Dysphagia Diet Standardisation Initiative) level advised by SLT. The identified actions are incorporated into ongoing improvement work and monitored by the Trust Food, Nutrition and Hydration Steering Group.
Speech and Language Therapists have also led on development of a Sip Testing Standard Operating Procedure (SOP) which was published in November 2024 along with a training video on Nucleus. This identifies patients who should be considered for a sip test and those for whom this is contraindicated, such as those with pre-existing swallowing difficulties.
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids
Since this incident occurred there is a new fluid assessment, as part of the Nucleus digital patient record, which is completed for all patients. This then prompts appropriate hydration monitoring dependant on the level of clinical need. The Food, Nutrition and Hydration Policy clearly states that when a patient lacks capacity a best interest’s decision should be made about ongoing fluid management, in consultation with family or carers.
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking
It is noted that the HCA (health care assistant) statement said the nurse looking after the patient had a delayed response, but that nurse was in the middle of giving another patient medication and said there was only a brief moment of delay until the patient swallowed their medication before they attended Mr Dulling.
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest. It is to be noted that at the time of the incident the Trust followed its previous policy on incident management. The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged the investigation undertaken following this incident was not timely nor optimal. This has been reviewed with the Medicine Care Group and the new policy requiring either hot
3 debrief or other form of incident response is now in place and is being used to proper effect. The Medicine Care Group has a dedicated Clinical Governance Team who review all reported patient safety events on a daily basis, appropriate learning responses identified and requested, and any severe or moderate harm patient safety events escalated to the Care Group quadrumvirate. Conclusion
We hope that this information provides you with assurance that the Trust has learned from this incident and have refined our procedures as a result. This will continue to be monitored carefully through our governance and assurance structures.
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment
It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not detailed enough and that a food chart was not instigated/completed when it should have been. The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in November 2024. There are currently several assessments, relating to eating and drinking and nutrition, that nursing staff undertake when a patient is admitted. These assessments are not all located in the same place and not as intuitive as they could be. We recognise that this is
2 not optimal and are in the process of bringing these assessments together into one section of Nucleus (electronic digital nursing record) and this is due to go live in January 2025. We are confident that this will significantly reduce the risk of essential information being overlooked. The Trust recognises the previous poor compliance in this area, as identified in Mr Dulling’s case, and this is a focus of current quality improvement project work. The Trust has completed a Patient Safety Incident Investigation (PSII) cluster review of Speech and Language Therapy (SLT) and swallow related incidents. This was presented to the Trust’s Serious Incident Group in December 2024 with an associated action plan. The PSII identified themes around lack of or delayed referral to SLT as well as food and drink given to patients that is not the IDDSI (International Dysphagia Diet Standardisation Initiative) level advised by SLT. The identified actions are incorporated into ongoing improvement work and monitored by the Trust Food, Nutrition and Hydration Steering Group.
Speech and Language Therapists have also led on development of a Sip Testing Standard Operating Procedure (SOP) which was published in November 2024 along with a training video on Nucleus. This identifies patients who should be considered for a sip test and those for whom this is contraindicated, such as those with pre-existing swallowing difficulties.
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids
Since this incident occurred there is a new fluid assessment, as part of the Nucleus digital patient record, which is completed for all patients. This then prompts appropriate hydration monitoring dependant on the level of clinical need. The Food, Nutrition and Hydration Policy clearly states that when a patient lacks capacity a best interest’s decision should be made about ongoing fluid management, in consultation with family or carers.
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking
It is noted that the HCA (health care assistant) statement said the nurse looking after the patient had a delayed response, but that nurse was in the middle of giving another patient medication and said there was only a brief moment of delay until the patient swallowed their medication before they attended Mr Dulling.
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest. It is to be noted that at the time of the incident the Trust followed its previous policy on incident management. The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged the investigation undertaken following this incident was not timely nor optimal. This has been reviewed with the Medicine Care Group and the new policy requiring either hot
3 debrief or other form of incident response is now in place and is being used to proper effect. The Medicine Care Group has a dedicated Clinical Governance Team who review all reported patient safety events on a daily basis, appropriate learning responses identified and requested, and any severe or moderate harm patient safety events escalated to the Care Group quadrumvirate. Conclusion
We hope that this information provides you with assurance that the Trust has learned from this incident and have refined our procedures as a result. This will continue to be monitored carefully through our governance and assurance structures.
Sent To
- Tees, Esk and Wear Valleys NHS Foundation Trust
- York and Scarborough Teaching Hospitals NHS Foundation Trust
Response Status
Linked responses
2 of 2
56-Day Deadline
9 Dec 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 11 September 2023 I commenced an investigation into the death of Stephen Frederick DULLING aged 69. The investigation concluded at the end of the inquest on 07 October 2024. The conclusion of the inquest was that: Stephen Frederick Dulling died from aspiration pneumonia as a consequence of an inappropriate diet as a hospital in-patient at York District Hospital.
Circumstances of the Death
On the 31st of August 2023 Stephen Frederick Dulling, who had Parkinson's Disease, symptoms of dementia and attendant swallowing problems, was admitted to the Acute Medical Unit of York District Hospital. On the morning of the 2nd of September 2023 Mr Dulling was eating toast for breakfast when he started to choke and went into cardiac arrest. He was subsequently found to have copious amounts of toast in his airway and gastric contents in his lungs leading to aspiration pneumonia. Mr Dulling died at the hospital on the 4th of September 2023.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.