Jack Willis inquest: RSPCA worker, 32, died in toilets at Yorkshire hospital and was not found for six hours

Jack Willis arrived at Doncaster Royal Infirmary on March 7 in a taxi, but did not check in at the A&E reception and thus staff had no record of his presence.

He was captured on hospital CCTV sitting in a waiting area for around five minutes before he entered the men’s toilets just after 9.30am, and was not seen alive again. Two cleaners raised the alarm when they found the cubicle occupied just after 3pm, but he could not be revived.

The inquest heard that Mr Willis, who worked as a call centre scheduler for the RSPCA, had long-term issues with alcohol misuse and a body mass index which put him in the ‘significantly obese’ category. The cause of death was given as alcoholic cardiomyopathy and a postmortem found that he had an enlarged heart and fatty liver.

A pathologist said it would have been difficult to observe any prior warning signs that Mr Willis was at risk of sudden death, though he would have suffered from general poor health.

The inquest was attended by Mr Willis’ three sisters, who spoke of how he had become ‘alcohol dependent’ and reclusive following the deaths of his parents when he was a teenager. He lived a sedentary lifestyle, spending hours playing video games, and did not socialise or have relationships though he had a university degree in biomedical science.

During lockdown, he moved into his own flat on Carr House Road, but gained further weight and his health suffered due to him working unsociable shifts. By the time he died, he could only walk around 50 yards and showed no interest in giving up alcohol.

He called 999 on the morning he attended hospital, but no transcript of the call was requested by the inquest and an ambulance was not sent for reasons that were not ascertained.

Doncaster Royal Infirmary matron Brett Storey explained that patients who had booked into A&E would be given three calls before staff assumed that they had left of their own accord without seeking treatment, but this process did not occur because Mr Willis’ arrival was not recorded on the system. His family say phone searches show he was trying to check in online after he had sat down, and believed he would have been too ill to queue at that point.

The hospital’s facilities lead, James Lowe, confirmed that cleaners were meant to conduct observational checks in the toilets at 10am and 12pm before a full clean at 2pm, but the first two did not take place due to a ‘busy’ shift and the 2pm clean was delayed to 3pm, when Mr Willis was found.

He admitted to not being aware of ‘shortcomings’ relating to the missed check cleans, and the hospital is now proposing that they become mandatory.

Recording a conclusion of death by natural causes, area coroner Louise Slater said: “It is likely that he could have been discovered earlier if the cleaning checks had taken place, so there is a missed opportunity, but because of the sudden nature of his death it is unlikely that it would have changed the outcome.”

Speaking after the hearing, Mr Willis’ sister Michelle Coll said: “The verdict was fair, but we would have liked a ruling to ensure it could not happen again. The ambulance didn’t come when he called it at 8am, he was too ill to queue and he was let down by the system.

“Jack was a gentle giant. Once lockdown came, he didn’t leave the house and he piled the weight on. This was never a witch hunt, but we don’t want this to happen again.”