Richard Handley Inquest

Family statement: Given the evidence we have heard in court, and the gross failures and missed opportunities noted, we are profoundly disappointed that the coroner felt unable to make a finding of neglect. Coroner's narrative attached

Coroner: thank you, the inquest is now concluded.

Coroner: profound changes have been made to services as a result of problems found in the events running up to Richard's death At this time I offer my condolences to Richard's family and those close to him on the loss of someone who clearly brought joy into so many lives.

Coroner: without their persistence and perseverance many of the reports for this inquest would not have occurred; their love for Richard is clear... From the exploration of Richard's death it's clear there were many steps that needed to be taken to ensure lessons were learned

Coroner apologises for length of narrative. I'm going to record those findings. In concluding the inquest today I would again wish to offer my thanks to all of those who have assisted in the conduct of the inquest itself, first and foremost the family

the provision of a care coordinator to proactively oversee and coordinate the different aspects of his care might well have prevented this extreme and tragic situation and the need for hospital treatment itself developing at all

There is no evidence any of the people involved in Richard's care did anything other than act in good faith to try and assist him at any time...

There was a missed opportunity to provide potentially life saving early intervention and additional procedures, if these were indicated clinically, that cld have been conducted before Richard's condition worsened and his death from complications of the condition occurred.

Richard did not receive the appropriate level of more senior input from surgical team and the additional medical specialist expertise from the critical care unit team, that should have occurred following those early raised scores.

Once at @IpswichHosp treatment did occur.. early signs of transient respiratory problems, post operatively, possibly due to aspiration of small amounts of gastric contents were picked up in the MEWS scores, there was a gross failure to act on these scores appropriately

The fact that they did not deem emergency referral necessary did not on balance of possibilities contribute, given he should still have survived

Immediate referral to the emergency dept of hospital for necessary treatment of evacuation of faecal loading did not occur when seen earlier in final week by the psychiatrist and GP trainee

on the balance of probability led to Richard developing significant worsening of his constipation and resultant faecal impaction. Without the recurrence of his constipation to the extreme extent it was found when he attended hospital, Richard's death would not have occurred

Changes in the diet Richard consumed and the monitoring of his bowel movements in period of time leading up to and following the transition of residential care to supported living at the home in which he lived

and bowel habits by those providing care to him to prevent episodes of reccurrent constipation.

Coroner: the narrative is that Richard Handley had Downs Syndrome, mental health problems, learning disabilities and a lifelong problem with constipation, possibly due to an underlying but unconfirmed bowel disorder and he required very careful attention to his diet

Coroner: my conclusion here, and complicating factors are such that a very brief narrative would not address all the issues that need to be addressed in such an inquest

Coroner: I am not recording a short form conclusion or including the word neglect because of the issues I've raised and the gaps in clinical evidence as well

Coroner: I think there are gaps in evidence in relation to causation, altho it is important in an Article 2 inquest I reflect the matters I've mentioned in respect of my findings, these are all central issues, a simple short form would not suffice, so will record a narrative

Coroner: if we add to that that although the condition shd have been survivable, its undoubtedly the case that complications arose, there are gaps in clinical evidence that will enable us to say with treatment at Time A or B that complication wld have been treatable