UK Inquiry Tracker

Kevin Fitton

PFD Report All Responded Ref: 2021-0169

Date of Report 28 May 2021

Coroner Veronica Hamilton-Deeley

Coroner Area City of Brighton and Hove

Response Deadline est. 23 July 2021

Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Police related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 23 Jul 2021

Coroner's Concerns (AI summary)

There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication and lack of coordination, all compounded by inadequate staff training.

View full coroner's concerns

There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately: (2) There was a failure to seek specialist support regarding Acquired Brain Injury (ABI): (3) There was a failure to understand the way Mr Fitton's ABI impacted on his abilities (4) There was a failure to understand how ABl impacted on Mr Fitton's substance use and vice versa_ (5) Communication between the various teams and individuals were poor. Lead and Co-ordination were lacking: There was a failure to react to the deterioration in Mr Fitton's living conditions, his being cuckooed, the downward slide in his physical health and the increase in his drug use (8) Staff received no adequate training in dealing with ABI. There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act. (9)_There was a reasonable_Care Act Assessment_in 2017 however_it was

VERONICA HAMILTON-DEELEY DL,

Responses

Responses from Sussex NHS Commissioners and Brighton and Hove City Council

Action Planned
Sussex NHS Commissioners have shared the report with commissioners to consider how long term service delivery can be improved for people with acquired brain injuries. Brighton & Hove City Council has designed and implemented a non-engagement policy, will develop a training course on mental capacity assessments and will continue to provide training courses on Acquired Brain Injury and self-neglect. (AI summary)

View full response

Dear Ms Hamilton-Deeley The late Kevin John Fitton - Prevention of Future Deaths Report On 24th May, Brighton and Hove Clinical Commissioning Group, part of Sussex NHS Commissioners, received the above report in accordance with the Coroners (Investigations) Regulations 2013. Sussex NHS commissioners have considered the report and discussed your concerns both internally and with other Health and Social Care partners in Brighton and Hove via the Safeguarding Adults Board. As you will be aware, the Safeguarding Adults Board held a Safeguarding Adults Review following the death of Mr Fitton. This review resulted in a number of recommendations which were reflected in the Prevention of Future Deaths Report. Having considered these actions the Safeguarding Adults Board has created an action plan to ensure that those recommendations will be achieved. This plan will be regularly monitored by the Safeguarding Adults Board to ensure progression at a reasonable pace. Within the plan the Clinical Commissioning Group is required to share the report with commissioners so as to give consideration to how long term service delivery can be improved for people with acquired brain injuries. The report has been shared with commissioners who are reviewing how acquired brain injuries can be specifically considered within the services that are commissioned. The Clinical Commissioning Group will continue to engage with partner organisations in the Safeguarding Adults Board to support service improvement for people with acquired brain injuries.

Sent To

Brighton and Hove Clinical Commissioning Group
Brighton and Hove Council
Brighton and Hove Health and Adult Social Care
Sussex Police

Response Status

Linked responses 1 of 4

56-Day Deadline 23 Jul 2021

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 17th September 2019 commenced an investigation into death of KEVIN JOHN FITTON: The investigation concluded at the end of the inquest on 5th 2021.The conclusion of the inquest was Drug related deathlmisadventure being myocardial infarction directly related to Spice use in circumstances where failure to obtain an urgent echocardiogram on 12th July 2019 represented missed opportunity to diagnose left ventricular hypertrophy and treat Mr Fitton in the High Dependency Unit: If the correct diagnosis had been made and if fluids had been administered in a more controlled way the outcome may have been different. The ongoing use of arose against a background of several years of ineffective care and support for stroke_induced acquired brain _injury_causing_self-neglect DL; the May spice

VERONICA HAMILTON-DEELEY DL;

Circumstances of the Death

Kevin Fitton suffered a catastrophic stroke at the age of 33 in 2010. Prior to that he was successful fit man enjoying his life in all respects Following the stroke, although properly assessed by the leading neuropsychologist so that the damage was fully recognised, his ongoing care never reflected his needs It was clear from the evidence that none of those providing that care understood the effects on him of his acquired brain injury. In particular during the nine plus years between the stroke and his death, Kevin's mental capacity was only assessed on three occasions, the last being in 2013 at the insistence of one ofhis sisters His last Care Act Assessment in 2017 was incomplete and not followed through: His care was branded ineffective by the Independent Safeguarding Adult Reviewer;. The main problems were his self-neglect, his almost daily use, latterly, of Spice and his vulnerability which meant he was taken advantage of by some members of the street homeless community. His Spice use took him to Accident and Emergency on several occasions in the last two to three years of his life_ The final admission was on 12th July 2019. Kevin required fluid support, however, the precarious state of his heart was not identified (a requested echocardiogram was not carried out)_ He became fluid overloaded, had cardiac arrest and died some 27 hours after being brought into Hospital by ambulance_

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action_

Copies Sent To

VERONICA HAMILTON DEELEY DL