An inquest into the death of Richard Handley, a 33-year-old man with Down's syndrome, has found 'gross and very significant failures' at nearly every stage of his care, culminating in his death from constipation. The coroner, Peter Dean, recorded a narrative verdict at Ipswich Coroner's Court, criticising Handley's care provider, GP practice, psychiatrist, social workers, and staff at Ipswich Hospital.
Handley died in November 2012 after a heart attack caused by inhaling liquid faeces, which he vomited due to a severely obstructed bowel. The coroner noted that his abdomen was the size of a woman 40 weeks pregnant. Despite opportunities to save him, the hospital failed to respond appropriately to his deteriorating condition, as indicated by his Modified Early Warning Score.
Failures at Bonds Meadow, the care home where Handley lived from 1999, also contributed. After the home deregistered and became a supported living facility in 2010, his strict diet was discontinued, monitoring of his bowel movements ceased, and his medication was changed to one with constipation as a side effect. His key worker admitted not knowing Handley had a chronic bowel condition.
Two days before his death, medics removed 10kg of faeces from his bowels, but a postmortem revealed much more remained impacted. After the operation, while receiving inadequate care, Handley vomited and inhaled liquid faeces, leading to a fatal heart attack. The coroner stated that potentially life-saving treatment was missed.
Handley's mother, Sheila, expressed disappointment that the coroner did not make a finding of neglect, but acknowledged his recognition that her diligence ensured reviews into her son's death occurred. His sister, Emily, a clinical psychologist, described his death as 'appalling' and highlighted the pain he endured.
