“I heard evidence at the inquest about the changes which have been made in the Hospital to…”

The coroner’s concerns

– (1) I heard evidence at the inquest about the changes which have been made in the Hospital to the nutrition services and I found these changes highly encouraging. I am now satisfied that there is an identified clinician with decision making responsibility in these circumstances. I am therefore not making recommendations which relate to the nutrition services within the hospital. (2) I am satisfied and remain gravely concerned about the lack of knowledge, respect and application of the Mental Capacity Act principles amongst staff treating patients who may not have capacity to make decisions for themselves. (3) Having heard evidence at the inquest I remain gravely concerned that Senior Clinicians have limited or no understanding of the Mental Capacity Act and apply it in a way which undermines the principles and requirements of the legislation. (4) I have heard evidence of online training tools which have been undertaken; whilst some training is better than no training it is clear to me that this training is insufficient to embed, in practice, knowledge and understanding of the Mental Capacity Act in a way which protects the vulnerable people it is intended to serve. (5) There appears to be a lack of understanding that decisions, when referred to in a best interests sense, are specific. This is not an overall catch all care plan. For example, the decision about whether Laura should receive an NG tube is one specific decision it is not bound up with ceilings of care decisions or any other decisions to be made with and for Laura. (6) Laura was non verbal but she could communicate. There was no evidence of anyone seeking Laura's parents’ views in a way which would be compliant with the Mental Capacity Act and even more worryingly, no evidence of clinical teams seeking Laura's views at all. (7) There was evidence in the clinical notes of one best interests form completed for Laura's admission for her eye surgery. The completion of this form, whilst a positive that it had been completed and is evidence that best interests had been considered, remains woefully inadequate in details and upon further exploration it was apparent that no attempt had been made to engage Laura in the decision making. (8) There appeared to be a view that although there was no formal best interests meeting for decisions about Laura's nutrition, clinical discussions were taking place with the right clinicians and therefore the decisions would not be changed by a best interests meeting. This is a fundamental misunderstanding about the requirements of the Mental Capacity Act and best interests, clinical decisions are not a substitute for the individual being supported to decide for themselves or for a decision made in their best interests to be reflective of their own views. In the same way as an individual with capacity may decline a treatment or intervention, even where it is recommended by a clinician in the highest possible terms, a treatment or intervention can be declined on Ps behalf where that decision is made in their best interests in accordance with the requirements of the Mental Capacity Act. Where necessary this may require application to the Court of Protection where there is a dispute. 3 (9) I remain concerned that all staff treating Laura have expressed the view that they did not expect Laura to die in this admission and were very upset when she did. I am therefore at a loss as to why the verification of death form records her as being an expected death. I would therefore challenge the Trust to consider whether there is a need to reflect on the completion of these forms and their importance and likewise whether there is a need to reflect on presumptions made about an individual’s underlying health conditions when completing verification of death forms. (10) I also remain concerned at a lack of understanding about the importance and relevance of Laura's hospital passport. This is a document which if read and understood by those treating Laura should mean that they can understand her, her communication style and her support needs so that she can be involved in decision making. It also should, if utilised properly, ensure that Laura's parents could have a level of reassurance that even if they were not there, Laura would be treated as if they were as staff would know how to communicate with Laura and understand what it was that she needed from them.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0137

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0