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Chandler's Ford man died as a result of nurses' failings, inquest hears
3:00pm Thursday 20th March 2014 in Winchester
AN INQUEST has heard how the “reckless disregard of patient safety” resulted in the death of a man who had long been suffering from a genetic disease.
Matthew Simmonds, who died at his mother’s home in Oakmount Road in Chandler’s Ford, was dying from a rare genetic condition called von Hippel-Lindau syndrome resulting in the need for round-the-clock care and invasive ventilation.
The court heard how Mr Simmonds, 39, had been discharged from Southampton General Hospital on July 6 2011 to spend the remainder of his life at home but died just hours later after one of the ventilators had not been turned on by either of the agency nurses contracted to care for him.
Dr Dominic Bell, intensive care consultant at Leeds General Infirmary, said in his report that the evidence indicated a “reckless disregard of patient safety” and had shown “identifiable shortfalls in the agencies”.
“I think ensuring familiarity with the patient and the defined care plans is part of the handover of care,” he said. “But I would say that the key priority remains the safety and well-being of the patient.”
Matthew’s condition caused tumours to grow in his neck and brain and doctors at Southampton General Hospital expected him to die “within days or weeks”.
In what had been described as one of the “most complex discharge plans the PCT had ever undertaken” Wimborne Nursing Agency and Team Medical arranged for nurses to carry out 24-hour care for Mr Simmonds for the duration of his remaining life.
However, yesterday one of the nurses contracted, Kadiatu Harris, said she felt the handover was rushed between herself and the duty nurse she had been taking over from, Fauzia Rust; something identified as a “failure” by the central Hampshire coroner Grahame Short.
Recording a narrative verdict, Mr Short, said: “The two nurses were not working as a team probably due to their opposing personalities. Neither nurse made appropriate observations of Matt after the changeover. I find that a proper handover is critical especially in a care plan as complex as Matt’s.
“It’s important that all necessary information is relayed from the first nurse to the second, both nurses having responsibility to the patient during this part. However the need to care for the patient during the handover is paramount. The nurses were too concerned with the handover and not enough of the needs of the patient.
“I find that this was a failure at the changeover of the ventilators to ensure that the ventilator was operational and that there was a further failure to ensure the patient was breathing properly.”
A framed picture of Mr Simmonds sat in the courtroom facing his mother, Zandra Simmonds.
When asked why she had requested the photograph to be present she said: “Because he is not a number he is a person. Perhaps I have set a precedent for it and people will follow these actions.
“He was just a wonderful son surrounded by friends and family who loved him dearly,” she added. “He was a wonderful person.”
Kerry Harnett, branch manager at Team Medical, said: “We would like to pass on our sincere condolences to Mrs Simmonds and her family for the sad death of her son, Matt. “Team Medical knew how important it was for Matt and his family to ensure that he was discharged home to die and worked hard in order to achieve this, within a short timescale, for the family.
“We were all deeply saddened by the subsequent events and appreciate that this week’s inquest will have brought back difficult and distressing memories”.
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