Failed by system, pensioner died weighing 4½ stone

On admission to hospital, the man was found to weigh just four and a half stone. Picture: Jane Barlow

An investigation was launched by the Mental Welfare Commission for Scotland into the death of the 65-year-old man, who also suffered with cognitive and communication difficulties.

Only identified as Mr JL and from a remote area of Scotland, he died in May 2012 after refusing medical examination, treatment and food and drink.

A post-mortem examination concluded the cause of his death was pneumonia and cancer of his tongue and mouth.

On admission to hospital, Mr JL was found to weigh just four and a half stone (28.5kg).

The commission became concerned the patient may not have had the capacity to consent to or refuse medical treatment.

It also said that both social care and NHS staff and professionals must have missed opportunities to intervene and  establish a new palliative care plan for him.

As a result of the probe, several recommendations have been proposed to improve the care for people with ongoing mental health issues including those who are reluctant to  accept treatment.

Colin McKay, chief executive of the commission, said: “Health and social care staff face difficult dilemmas where a person with ongoing mental health issues is reluctant to accept treatment for physical conditions.

“In this case, although a number of professionals were concerned about Mr JL’s well-being, they did not ensure that a proper assessment was made of his capacity to make such a major treatment decision.

“Even if it was agreed that he was entitled to refuse treatment, there should have been more consideration of how best to support him through a serious and ultimately terminal illness.

“As a result, opportunities were missed to give Mr JL as comfortable and dignified a death as possible.”

A total of 17 recommendations have now been relayed to the care provider, the unnamed local authority, the NHS board responsible for his care and treatment, Healthcare Improvement Scotland and the Scottish Government.

These include better training in incapacity legislation and more effective support for sole care workers, particularly where a service-user may be at risk including them being unable to express their wishes.

Margaret Watt, who chairs the Scottish Patients Association, said: “A large link in the chain has been missed here. You would have thought that in 2012 someone would have noticed his sudden weight loss. To reach four and a half stone doesn’t happen in just one or two weeks.

“The staff involved most definitely need further training and more support in carrying out their duties because this is  unacceptable.”

The Scottish Government said it had accepted the commission’s findings “in full”.

A government spokesman said: “First and foremost, our thoughts are with the friends and family of Mr JL.

“We are clear that proper  assessments should always be carried out in these circumstances, and that appropriate levels of support and care should be in place to help people at the end of their lives.

“We have recently asked Healthcare Improvement Scotland to review their guidance on reporting and review of adverse events.

“The next version of the national framework will help to ensure better co-ordination between different organisations when conducting reviews.”