A CORONER has severely criticised hospital staff for neglecting a patient suffering from Creutzfeldt–Jakob disease who disappeared from a hospital via a secure baby unit and was later found dead in a field.
Ex-police officer Graham Roskell, 65, was in a confused mental state and should have been receiving one-to-one nursing care while at Harrogate District Hospital, an inquest heard.
Recording a narrative verdict, Coroner Robert Turnbull said he found there had been “serious security breaches” at the hospital, including Mr Roskell’s access to a baby unit as he made his way out.
The coroner added: “It appears there was confusion with regard to who was in charge of the ward that day. Two shifts had the opportunity to take responsibility for actioning one-to-one nursing. The fact no one took action is a major concern and a major contributor.”
The coroner said staff “did not treat one-to-one nursing as seriously as they could have. The matter should have been escalated and implemented”.
He added: “One-to-one nursing would have minimised and managed the risk. There is evidence of gross failure on behalf of some or all of the hospital staff I do find there was neglect in this particular case.”
Grandfather Mr Roskell, from Harrogate, was admitted to the Oakdale ward, for stroke patients, in October 2012 suffering from sporadic Creutzfeldt–Jakob disease (CJD) – a degenerative brain condition causing confusion and anxiety.
Hospital staff decided to treat Mr Roskell for a central nervous system infection.
He was admitted for monitoring over the next two days but he did not appear to respond to the treatment and his condition appeared to be deteriorating. Psychiatric nurse Margaret Cooper attended the ward and was concerned about him leaving.
She felt he “lacked capacity” to make decisions for himself and spoke to nursing staff to recommend one-to-one nursing and possible plans for deprivation of liberty rather than moving Mr Roskell to a psychiatric ward.
The nurse advised Mr Roskell’s doctor to pursue one-to-one care in relation to his distress, but this advice was not acted on, the inquest was told.
The coroner heard that the day Mr Roskell disappeared, the ward was extremely busy, as they were missing a ward manager, and was described as “chaotic”. It was so busy that routine patient observations had not been done.
Mr Roskell left the ward and made his way to a secure children’s ward and managed to follow a staff worker through a secure door.
Confronted by two other secure doors, Mr Roskell was let through by a nurse who assumed he had been buzzed through. Later, Mr Roskell was seen by CCTV footage climbing over a wall at 7.45am. It was not until 8.30am that he was discovered missing and police were called at 9am after staff had searched the grounds.
Mr Roskell’s body was found in a field near Wetherby on November 14 – 12 days after he vanished from the ward.
The inquest heard the cause of death was hypothermia.
Harrogate and District NHS Foundation Trust’s medical director, Dr David Scullion, said: “We would like to express our deepest condolences and sincere apologies to the family of Mr Roskell. We accept the findings of the coroner and acknowledge his conclusion.
“Our investigation into the death of Mr Roskell has led to a number of initiatives to improve the safety of patients, which we consider to be of paramount importance.
“We have already increased the number of nurses working on wards that care for elderly patients, where people who are confused are most likely to be accommodated, and addressed the security issues arising from this tragic incident.”
After the hearing, Mr Roskell’s family said: “We would like to thank the coroner and the trust for accepting that Graham was neglected whilst in the care of Harrogate Hospital and also that there was a serious breach of security by hospital staff allowing him to enter unchallenged into the secure children’s ward.
“However, we are glad that the evidence has now been heard as listening to it all again clearly brings back painful memories. This has devastated our family and over a year later he is still in our thoughts daily.”