Exclusive: Trust criticised after second inquest into death of women detained in hospital died of malnutrition
“Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned.
A second inquest into the tragic death of a 45-year-old woman called Jennifer Lewis has found the mental health hospital where she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition.
Mental health charity Rethink has called for improvements to physical healthcare for patients with severe mental illness which they say are “all too often ignored”, while experts at think tank the Centre for Mental Health warn those with mental illness are dying too young as the system “still separates mental and physical health.”
Ms Lewis died in July 2017 following the impacts of malnutrition whilst she was an inpatient the Bracton Hospital run by Oxleas Foundation Trust.
Her family have had to fight for a second inquest, which concluded on 8 November, after coroners first failed to consider negligence from the hospital.
Ms Lewis had a long term diagnosis of schizophrenia and her family described how she lived a full life, completed a medical degree, and would give lectures about living with mental illness. However, after undergoing bariatric surgery, against the wishes of her family, her mental state declined and she was admitted to the Bracton Centre, run by Oxleas, in 2014.
Ms Lewis’s sister Angela has described to The Independent how in the year before her death she lost her hair, suffered from diarrhoea, developed sores on her legs as she effectively “starved to death” from malnutrition.
According to evidence heard at the second inquest, Whittington Hospital had provided Oxleas with dietary information as Ms Lewis needed a high protein diet.
However, whilst at the Bracton Centre, Ms Lewis did not receive the correct diet, instead she was allowed “three sandwiches” or six slices of bread a day, which was contrary to dietary recommendations for post-bariatric surgical patients, her family has said.
Ms Lewis’s family were told by the hospital that her sister chose to have the diet she had, however they argue the trust has never provided evidence of Mental Health Capacity assessments it said were carried out.
In an interview with The Independent, Ms Lewis’s sister Angela, said in the year leading up to her death when the family warned doctors she was “starving to death”, these concerns were dismissed and said the hospital “will not let it come to that.”
She described that prior to her death Jennifer suffered hair loss to the point where she was “practically bald”, her periods had stopped, she lost some of her eyesight and due to a serious protein deficiency, had severe swelling of her legs. Due to the extent of the swelling, Ms Lewis’s skin “split” which resulted in sores.
Her sister added: “Jennifer had diarrhoea, which is a side-effect of malnutrition, and she was too weak to go to the toilet or to clean herself up, so the faecal matter entered the open sores in her legs. As a consequence, when she died, she had septicaemia.”
“The last time I saw Jennifer at the Bracton Centre, it was really hard to look at her because she was in such a woeful state. The sores on her legs were weeping, and she was shuffling like a 90-year-old, with dirty bandages hanging from her legs.”
“Before she got ill, Jennifer was always immaculately turned out. She was tall and willowy. Jennifer loved clothes, loved to look good, hair and nails done and to see what happened to her was really hard. If Jennifer from 2007 could have seen herself before she died, she would have been absolutely horrified.”
Ms Lewis family have also raised serious concerns over the electro-convulsive therapy given to her several months before she died and they say they were told the treatment would make her more “compliant” to her care regime. However they noted following ECT her “word-finding skills and thinking skills significantly deteriorated.”
Angela Lewis described how Oxleas and medical hospitals, including The Whittington Hospital, would either just deal with Jennifer’s physical health or mental health needs but rarely in conjunction.
She said: “Patients on a psychiatric ward are not one dimensional. They may arrive on acute mental health wards with any manner of physical health problems. To neglect the holistic needs of the most vulnerable patients who are detained by the state, is totally unacceptable to us as a family”.
“Jennifer was not responsible for her own care, by virtue of the fact that she was detained under section three of the Mental Health Act. So, to make Jennifer responsible and to blame her for her own death is wholly unethical. We still cannot fully believe that Jennifer was allowed to starve to death whilst in the care of the state.”
Failures to address the physical health of people with severe mental illness have been raised by coroners previously. In one example last year a coroner in London found an acute hospital failed to treat a man’s spinal injury as his symptoms were mistaken for mental health difficulties.
Alexa Knight, associate director for Policy and Practice at mental health charity, Rethink Mental Illness told The Independent: “Jennifer Lewis’s death is a tragic example of the consequences when the physical health needs of people living with severe mental illness are neglected. Our thoughts and condolences are with Jennifer’s family.
“The physical health needs of people living with mental illness are all too often ignored. Whether people are receiving inpatient care or living independently, it’s unacceptable that people severely affected by mental illness are more likely to face reduced life expectancy compared to the general population.
She said that physical health checks can help identify and manage risks to health, but the number of people receiving this in the community is well below target, so effort must be made to improve access to this.
In a statement to The Independent, Andy Bell, deputy chief executive, said: “People living with mental health difficulties die too soon, most often because of untreated or poorly treated physical health problems. It’s vital that anyone being treated for a mental health condition gets effective physical health care, too.
“This means being seen as a whole person and having all of their health needs taken equally seriously. Tragically people are dying too young when their needs are not properly met by a system that still separates mental and physical health when they are so closely connected.”
Oxleas Foundation Trust was approached for comment.