Man killed by Covid 19 after 'gross failure to provide basic medical attention'

John Hoare, of Saltaire, contracted the virus at Airedale General Hospital after he was detained under the Mental Health Act and died on March 31 in 2020.

An inquest heard the 62-year-old was suffering from schizoaffective disorder, which has symptoms similar to schizophrenia and bipolar disorder, and he deteriorated after his GP at Low Moor Medical Practice failed to prescribe a mood stabiliser called lithium citrate.

Coroner Crispin Oliver said as a result his “mental health declined critically” and he had to be sectioned.

In a prevention of future deaths report, the coroner said Low Moor Medical Practice must take action to avoid another “gross failure”.

The inquest was told that Mr Hoare had been discharged from Bradford Royal Infirmary to Norman Lodge Care Home in January 2020, after he was treated for cognitive problems and lithium toxicity.

Staff at the home and his GP surgery were told that he required a number of prescribed medications for his condition including lithium citrate. It was provided in his first prescription, but omitted from the second as a GP decided he needed a blood test.

The test results confirmed on February 4 that Mr Hoare could continue taking the medication but he did not receive another prescription from his GP and his mental health deteriorated.

The coroner said he was eventually prescribed the medication by a nurse practitioner on March 5, but “by the time it was resumed his condition was so severe” that he had to be detained under the Mental Health Act.

He was admitted to a mental health ward at Airedale Centre for Mental Health the following day and caught Covid-19 while he was being treated in hospital.

“There was a gross failure to provide basic medical attention,” the coroner wrote.

“There was an inherent importance in not delaying or interrupting lithium; there had been numerous requests and reminders from the care home about the provision of lithium; there was a material delay during which nothing was done by the GPs` surgery.”

He added: “The GP who gave evidence for Low Moor Medical Centre was a conspicuously honest witness and clearly exceptionally caring.

“He had been devastated by what had occurred in this case. But the fact remains, secondly, that there had been a gross failure to provide basic medical attention in relation to lithium prescribing and dispensing that resulted in John being sectioned.”

The coroner said he cannot conclude that Mr Hoare was at a “greater risk of infection” in hospital, so he cannot say the care home resident’s death was caused by the decision to section him.