‘Lessons learned’ after covid patient’s oxygen disconnected at Harrogate hospital, inquest hears

Harrogate hospital has “learned lessons” following the death of a woman who became disconnected from her ventilator when she was left alone in a room with the door closed.

Karen Smith was 44 when, in October 2020, she was admitted to the hospital with covid.

She was put on a temporary intensive care ward that had been set up by Harrogate and District NHS Foundation Trust to deal with the high demand of the pandemic.

An inquest heard this week Ms Smith died on the ward after her oxygen mask became disconnected.

The continuous positive airway pressure (CPAP) oxygen machines used on the ward were not connected to the nurses’ station in the way they were on the established ICU.

When Ms Smith’s mask came off and the tube became disconnected around 5am on Saturday, October 24, although the machine’s alarm sounded, there was no way of it sending a signal to the nurses’ station for a rapid response.

The previous day, the hospital’s infection control team had visited the ward and recommended that the doors to each bay, which had been open, should be closed to help reduce the spread of covid.

Dr David Earl, a consultant in anaesthesia and critical care, told the inquest:

“The doors were closed on that Friday and I don’t think enough work was done to recognise the implications of how that might make nursing quite difficult, because you can’t hear behind the doors.

“This is when things start to go a bit wrong, I think, on that Friday.”

On the Saturday evening, a nurse who was covering a meal break had left Miss Smith’s bay to go to the toilet urgently. She had no way of contacting another nurse to cover for her, but believed the original nurse was about to return from her break.

The inquest heard that, during the pandemic, staff were required to remove extensive personal protective equipment (PPE) and go to a bathroom nearby, rather than the one on the ward, which took much longer than usual.

When the nurse she was covering for returned, the disconnection was noticed and Ms Smith’s mask had been completely removed.

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Dr Earl told the inquest many patients find CPAP masks uncomfortable and can attempt to remove them when slightly disorientated, such as when waking up.

The machine’s log indicated Ms Smith had been without hers for around four-and-a-half minutes. A new mask was immediately brought from the store cupboard nearby.

Staff said they hoped the short time of disconnection meant that Ms Smith would not have been affected by the lack of oxygen supply.

The inquest heard that, although her blood oxygen levels quickly rose again, it became apparent to the team on the next shift that she was more sleepy and less responsive than usual.

That night, as her condition further deteriorated, staff called her mother, but she was not allowed to come into the hospital because of covid restrictions.

Addressing Ms Smith’s mother Audrey and brother John, who were at the inquest, Dr Earl said:

“At the time, we were following national guidelines about visiting.

“As someone who worked through all of this, not having visitors all the time was terrible. On intensive care, we spend a lot of time with families getting to know them. To suddenly not have families there was absolutely awful for us, but we know it was even worse for families like yourselves.

“It we could go back, we would get you straight in when we knew [she was dying]. Now, that’s the national guidelines.”

Ms Smith said her daughter had been well enough the day before to be messaging her friends. However, Dr Earl said given the number of days she had been reliant on the CPAP without any sign of improvement, his experience with covid patients suggested she was more likely than not to have succumbed to the virus in the end.

Walkie-talkies introduced

Dr Earl said the hospital had “learned lessons” from Ms Smith’s death and a number of changes had been implemented to prevent the same situation arising again, including changes to nurse rostering and the introduction of walkie-talkies to allow nurses to communicate with each other even when in separate rooms.

He added:

“We realise we can’t make everything perfect, but we try to list all the things where we think there’s a potential danger there and try to minimise them.

“In this new area, we had one of those risk registers and recognised it was constantly evolving, but in these circumstances, it was the best we could do.”

Delivering a narrative conclusion, senior coroner for North Yorkshire Jonathan Heath said Ms Smith, who lived in Wetherby, had died from a hypoxic brain injury caused by becoming disconnected from her oxygen machine. A secondary cause of death was her high body mass index.

Mr Heath said there was no evidence of how Ms Smith’s mask came to be removed and the tube disconnected, so he did not want to make any assumption.

Mr Heath said:

“I am satisfied that a ‘prevention of future deaths’ report is not required.

“Whatever I would be saying to the hospital appears to have been addressed already.”

Knaresborough solicitor died in fatal fire caused by candle, inquest finds

A house fire which led to the death of a Knaresborough solicitor is likely to have been caused by a candle, an inquest heard today.

Lynda Delf Greenwood died at the scene of the fire which destroyed her home in Brearton in April this year.

The inquest heard both police and fire officers conclude that a candle on a coffee table in the living room was thought to have been the origin of the fire.

The fire took hold thanks to wood and other materials near the open fire, which was not lit.

Fire investigator Tony Walker told the inquest:

“It did surprise me a little just how quickly it had spread to the upstairs bedroom which was so badly affected by the fire that it [collapsed] down into the living room.

“When I was speaking to [Mrs Greenwood’s daughter] Camilla, I was informed Lynda kept a large amount of fire lighters and kindling by the side of the fire which may have been feeding the fire.”

Earlier in the week, the court heard, Mrs Greenwood had had an operation on her foot and was wearing a “boot” for support.

However, on the day of the fire, Saturday, April 2, she appeared well and uninhibited by the boot. Camilla had gone shopping and to have beauty treatments in Knaresborough with her mother.

They returned to the house in Brearton where Mrs Greenwood, who was 67, had cooked dinner. Camilla left just after 8pm, having made plans to see her mother the following day for a family event.

Dog barking

The inquest heard Mrs Greenwood then spoke to her sister-in-law, Samantha Nattress, over the phone just after 8.30pm. Mrs Nattress told the hearing there was nothing unusual about the phone call, other than one of Mrs Greenwood’s five dogs barking in the background on two occasions during the 45-minute call.

The phone call ended just after 9.20pm when Mrs Greenwood said she was going to bed.

Neighbours noticed the fire just after 10pm and called the fire service, as well as rushing to the scene to help. Three men went to the conservatory door and rescued the dogs, while also calling into the house for Mrs Greenwood.

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The inquest heard firefighters arrived just a few minutes later. Police and paramedics also attended.

Mrs Greenwood was found lying in the hallway behind the door to the kitchen. She was taken outside into the garden where first firefighters and then paramedics attempted to resuscitate her, but without success.

The Brearton house destroyed in the fatal fire

The Brearton house destroyed in the fatal fire.

Giving evidence at the inquest, DS Louise Pegg said she felt it was likely Mrs Greenwood, having discovered the fire, had been trying to get to the dogs’ room on the other side of the kitchen.

She added:

“I’m led to believe there was quite a lot of furniture in [the house]… Once the fire had taken hold, there was material that was combustible.

“Camilla told me that it’s rare for her mother to use a candle, but on that occasion she had lit a candle.”

Mr Walker said he had also concluded the dogs were in the area next to the conservatory where they were usually kept and that he believed two battery-operated smoke alarms were not working. He added:

“If Lynda had come out of her bedroom door when she first detected that smell of smoke, by that time there would have been a lot of product combustion in that part of the hallway. There will have been a lot of smoke.”

‘Loveable fruitcake’

In statements read out by North Yorkshire area coroner Catherine Cundy, friends and neighbours described Mrs Greenwood as “bubbly” and that she “would help anyone out with anything”. The court heard she was an active member of the community and in the village church and one neighbour said she was “a lovable fruitcake”.

Mrs Greenwood ran her own solicitors’ practice in Knaresborough and, in October 2021, invited neighbour Leighton Williams to join her as a partner in the firm, which he did.

Her daughter Camilla had moved back home after university in December 2020, but left the following year. Mrs Greenwood’s parents had both lived in an annexe next to the house but had died in 2021.

Camilla described her mother as “one of a kind” and “fun to be around” in a statement read to the inquest. She said she was “extremely capable”, “high-functioning” and “organised”. While her mother could seem “a little forgetful” sometimes, Camilla said this was only over minor matters and she loved to organise family occasions.

The court heard a post-mortem examination found evidence of Mrs Greenwood’s prescription medication in her blood, as well as some alcohol, which could have been enough to make her disorientated or cause blurred vision.

There was evidence of toxic levels of carbon monoxide inhalation, the court heard.

Ms Cundy recorded a verdict of accidental death in the fire, most likely caused by the candle.

Inquest hears how Harrogate boy had taken multiple drugs

An inquest into the death of 16-year-old Ben Nelson-Roux heard how he had multiple drugs in his system, including cocaine and diazepam, when he died.

Ben, a former student at St Aidan’s Church of England High School, died in Harrogate on April 8 2020.

His body was found by his mum, Kate, at Harrogate Borough Council-run homeless hostel Cavendish House. He had been living there since February of that year.

The hostel on Robert Street is intended for adults and has 9 bedsits.

The inquest into Ben’s death is expected to last twelve days and began this morning at the North Yorkshire Coroner’s Office in Northallerton.

Ben, who left St Aidan’s in 2019, was a known drug user and two days before he died was deemed by NHS Child and Adolescent Mental Health Services (CAMHS) to be ‘at significant risk of death’.

He was also recognised by authorities as a victim of child criminal exploitation from county lines drug dealers.

The inquest into Ben’s death will explore the decision by the North Yorkshire County Council and Harrogate Borough Council to place Ben in an adult homeless hostel, given his age, vulnerability, and what was known about his lifestyle at the time.

Toxicology report

The inquest heard how cannabis, tablets and white powder were found in Ben’s room when he died.

Two days before his death Ben attended accident and emergency at Harrogate District Hospital where he said he had ingested a number of diazepam tablets as well as crack cocaine.

Dr Stephen Morley, toxicologist, told the inquest that blood and urine reports identified MDMA and cocaine as well as the painkillers diazepam and buprenorphine.  Mirtazapine and temazepam, used to treat depression and insomnia, were also found.

However, Dr Morley said all the drugs were found in “relatively low” concentrations.

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Dr Carl Gray, consultant pathologist at Harrogate District Hospital, said he was unable to undertake a full post-mortem on Ben’s body as it took place during the first covid lockdown.

He said:

“The cause of death cannot be certain as there was no internal dissections due to the pandemic. Multiple drugs were present but were low and the effects were debatable.”

Dr Gray added:

“My opinion on the balance of probability is that the most likely cause of death was multiple drug abuse and cocaine toxicity”.

Died alone

North Yorkshire Police detective sergeant Dominic Holroyd said police studied CCTV of Ben’s last movements in the hostel.

He said the footage ruled out anyone else being involved as Ben was the only person seen entering or leaving his room.

DS Holroyd added that following Ben’s death, police had made two arrests on suspicion of supplying him with the drugs but the investigation was dropped due to lack of evidence.

He also said there was no evidence that anyone at the hostel supplied him with the drugs.

The inquest continues.

Solicitor Lynda Greenwood died of smoke inhalation, inquest hears

An inquest into the death of prominent local solicitor Lynda Greenwood heard today that she died of smoke inhalation when her house caught fire.

Ms Greenwood, who founded Greenwoods Solicitors in Knaresborough in 1991, died on April 2 at her home in Brearton. She was 67.

Her home was severely damaged in the blaze, which occurred at about 10pm on a Saturday night.

Assistant coroner Jonathan Leach gave the cause of death at today’s brief opening inquest in Northallerton. He said she was divorced her maiden name was Nattress.

Me Leach added:

“She was at home on April 2 when a fire broke out, as a result of which she died at the scene.”

The inquest was adjourned until a later date.

Ms Greenwood was born in South Shields but grew up in Knaresborough where she attended King James’s School before completing a law degree at Kingston University and becoming a partner in a Surrey law firm.

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After having her daughter, she set up Greenwoods Solicitors in her home town.

A statement on the company’s website says:

“On Saturday 2 April 2022 our colleague, our friend, our Lynda, was taken from us in the most tragic of circumstances.

“Lynda touched the hearts of everyone who met her and we have been overwhelmed by the number of kind messages we have received.”

 

 

 

 

Inquest hears Harrogate woman, 23, undergoing gender reassignment died from suicide

An inquest heard today found a 23-year-old Harrogate woman died of suicide.

Lisbeth Badrock lived on Leeds Road in Harrogate and was six years into a gender reassignment process when she died.

Today the inquest, held at Northallerton Coroners Court, heard her cause of death on November 16, 2021 was suicide.

Ms Badrock was transitioning from male to female, and had begun the process of taking hormonal medication.

The lead clinician in Ms Badrock’s care, Dr Laura Charlton, said she had spoken at length with Ms Badrock about her transition. Having been on medication for some time the next step would have been surgery.

Dr Charlton had discussed her surgical options and said Ms Badrock said she felt she would benefit from facial and neck surgery.

Mark Vickers, another member of Ms Badrock’s care team, said he had spoken to her in the months prior to her death about her mood levels.  She had reported her mood was dependent on the hormone medication she was taking but that is was generally good.

He had arranged for another appointment in January 2022.

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The inquest heard that  when speaking to officers following her death, her family and partner said she suffered with “bouts of depression”.

Ms Badrock’s father, Jonas Hartley, also gave a statement about his daughter who was working as a care worker at the time of her death. He said:

“She was generally happy, we thought she was becoming the Beth she wanted to be. I didn’t think she was at risk”.

Concluding the inquest, coroner Mr Jonathan Leach said:

“It is clear to me Beth was a 23-year-old in the midst of transitioning for which she was supported by doctors, colleagues and family. I am satisfied on this count due to the manor of her death that it was intentional and I conclude it as a suicide.”

Ripon construction worker’s death an accident, inquest concludes

An inquest into the death of Dean Christopher Myers, who was struck by a digger on a Ripon construction site, has concluded it was an accident.

Mr Myers, 56, died on January 13 last year whilst working as a ground worker for the HACS group at a site on Whitcliffe Avenue.

The Scotton man’s cause of death was a severe head injury due to blunt force trauma. Today’s hearing at Pavilions of Harrogate examined the circumstances surrounding his death.

It heard that at the time of his death, Mr Myers was stationed in a manhole in a three metre-deep trench, which had been dug for sewage pipes.

Fellow construction workers Lee James and Andrew Temple said it was not unusual for workers to be positioned in the manhole.

Mr James was standing at the top of the trench, acting as a guide for machine operator Mr Temple. Both said the arm of the digger had got stuck, probably on some limestone in the ground, and this was when Mr James saw Mr Myers put his head out of the manhole to look at what was stopping the digger.

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Mr James said he shouted to Mr Myers twice but got no response so he urged Mr Temple to stop before getting into the trench to check on Mr Myers.

The court heard the digger had become unstuck and started to move again, which was when it struck Mr Myers.

‘No sign of negligence’

A statement read out by police officers at the scene said:

“This was an unfortunate accident caused by Mr Myers putting his head out of the hole at the wrong time. There was no sign of negligent or criminal activity.”

In a witness statement, health and safety inspector Benjamin Cairns said it was a typical construction site set-up with no obvious safety concerns.

When asked by coroner Jonathan Leach whether it was appropriate for Mr Myers to be in the manhole, he said:

“If I witnessed that [a construction worker in the man hole] on site I would have asked the person to leave.”

Mr Myers’ work colleagues at the inquest described him as “more conscious than most” about safety and an experienced construction worker. They said they were unsure why he stuck his head out.

After hearing multiple statements, the nine-person jury concluded Mr Myers’ death was an accident.

Mark Smith, managing director of the HACS group, which employed Mr Myers for eight years, told the Stray Ferret afterwards:

“We would like to say how sorry we are at the loss of a valued colleague and our thoughts are with the family at this time.”

Death of Harrogate man, 45, was due to drugs, inquest hears

The death of a 45-year-old man at a Harrogate hostel was due to “multi-drug toxicity”, an inquest heard today.

The inquest into the death of Stephen Paul Cattanach on October 26, 2020 was heard at Northallerton Coroners Court this afternoon.

At the time of his death, Mr Cattanach was living in temporary accommodation provided by Harrogate Borough Council at Cavendish House on Robert Street.

The inquest heard the 45-year-old was found in his room by a member of staff on the afternoon of October 26.

Dr Joy Shacklock, of the Spa Surgery in Harrogate, told the inquest Mr Cattanach had a “complex history of drug and alcohol addiction and mental health issues”.

Dr Shacklock added her patient had suffered a number of overdoses, most recently twice in July 2020. She said Mr Cattanach insisted neither was intentional.

A toxicology report performed after his death, found high levels of drugs, including morphine and heroin, in his blood.

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He had previously been helped by North Yorkshire Horizons, an adult drug and alcohol recovery service. Mr Cattanach reached out for support from Horizons five days before his death and had a follow-up appointment booked for October 27, the day after he died.

Coroner Jon Heath agreed with the post-mortem assessment and concluded that his death was drug related. He said:

“I am satisfied that the cause of death was multi-drug toxicity, this alongside the police evidence which found no suspicious circumstances or suicidal indications suggests he did not intend to take his own life.

“I am able to conclude that on the balance of probability his death was drug related.”

Inquest concludes no single factor led to Harrogate woman’s suicide

An inquest into the death of a Harrogate woman has concluded that no single factor contributed to her taking her life.

Sarah Tatlow, 57, died at home on March 26 last year. At the time of her death she was undergoing treatment for an aggressive form of cervical cancer.

The two-day inquest in Northallerton, which ended today, heard Ms Tatlow’s husband, Julian Tatlow, question the actions of her doctors in the months leading to her death.

Mr Tatlow said his wife only became fully aware of her “poor prognosis” when a letter was sent days before her death.

The letter was written by Dr Isa Edhem, a consultant urological surgeon at Harrogate District Hospital, to Ms Tatlow’s GP practice. Mr Tatlow described the letter as “cold and insincere” and said it contained details not made clear to them during their consultation with Dr Edhem.

Harrogate District Hospital.

Harrogate District Hospital.

Mr Tatlow questioned members of his wife’s care team during the inquest, asking if they had made it clear to her how aggressive her cancer was. The doctors said they were sure Ms Tatlow knew her cancer was aggressive.

The coroner, Oliver Longstaff, said he took Mr Tatlow’s arguments into consideration but that there was no evidence the letter had a direct link to Ms Tatlow’s death.

Mr Longstaff concluded:

“Since it’s not known when that clinical letter arrived and indeed whether she had seen it, it is inappropriate for me to consider that a direct causal link can be found.

“Even if the letter arrived on March 26 and even if she had taken in the content, is there evidence this letter provoked her suicide over other factors?

“She was facing drastic surgery. I find it unrealistic to single out one factor only and say one was a trigger to this tragedy.”

He concluded the death was due to suicide and there was a clear link to her cancer.

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Hospital action plan

Mr Longstaff then read out an action plan written by Dr David Earl, on behalf of Harrogate and District NHS Foundation Trust, setting out a number of recommendations the hospital had put into place following Ms Tatlow’s death.

These included a protocol whereby, rather than sending letters to a patient’s GP, they are sent directly to the patient, explaining their prognosis and management plan. This is due to be rolled out across all departments by autumn this year.

It also suggested doctors would be more proactive with referrals to the cancer clinical psychology team if patients are struggling to cope.

Mr Longstaff said the trust’s action plan meant there was no need for him to write to the trust outlining his own recommendations.

Dr Jacqueline Andrews, executive medical director at Harrogate and District NHS Foundation Trust, said in a statement afterwards:

“We would like to offer our deepest sympathies to the family and friends of Sarah Tatlow, and our thoughts are with them at this difficult time.”

‘Cold and insincere’ letter from Harrogate hospital led to suicide, inquest hears

A Harrogate man has told an inquest a “cold and insincere” letter from Harrogate District Hospital led to his wife to take her own life days later.

Sarah Jane Louise Tatlow, 57, died on March 26 last year at the home she shared with her husband and two sons in Harrogate.

She had been undergoing treatment for an aggressive form of cervical cancer.

Julian Tatlow told today’s opening day of the inquest in Northallerton that his wife was not fully aware of her “poor prognosis” until she received a letter from one of her doctors at Harrogate District Hospital days before her death.

The letter was sent following an in-person consultation with Ms Tatlow and her husband on March 17.

Ms Tatlow, who was a director of management training and development consultancy Kronos Learning, did not share the letter with her husband, who found it in the days after her death.

He described the letter as “cold and insincere” and said it contained details not made clear to them during the consultation.

He said the use of words such as “slurry” to describe the kind of faecal matter that would have ended up in his wife’s stoma bag, and the shock of her “poor prognosis” would have made his wife question “what is the point?”.

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Mr Tatlow told the inquest in Northallerton:

“I believe if she didn’t receive a copy of this letter, I may still have a wife and my sons a mother.”

The consultant who sent it responded to say:

“The extent of her cancer was confirmed on 10th March after numerous scans. I believe Sarah had come to the conclusion [of the severity of her cancer] following numerous consultations with myself and colleagues.”

Cancer diagnosis

The inquest heard that Ms Tatlow suffered frequent urinary tract infections in late 2020. A routine cervical screening in January 2021 then diagnosed cancer.

Dr Allison Amin, a consultant gynaecologist at Harrogate District Hospital, said she knew instantly it was an aggressive form of cancer that had spread to her pelvic area.

But Mr Tatlow said in an opening statement, which was read out at the inquest, that neither he nor his wife was aware of her “poor prognosis”. He said all the consultations had suggested that operations could “give her a better quality of life”.

Mr Tatlow asked each doctor if they had made it clear to his wife how aggressive her cancer was. Each doctor said they were unable to confirm their exact words but were sure Ms Tatlow knew her cancer was aggressive.

Mr Tatlow said to one of the doctors “my recollection is entirely different”.

He also asked why none had referred his wife to her GP for depression during a time in which, he said, she was clearly struggling.

At the time of her death, Mrs Tatlow was waiting for two surgeries that were due to take place early in April.

The inquest, led by coroner Oliver Longstaff, is due to conclude tomorrow.

Inquest finds homeless Harrogate man endured a ‘drug-related death’

An inquest heard that a “fatal selection of drugs” was found in the body of a 40-year-old Harrogate homeless man.

Matthew Luke Chandler, a resident at Harrogate Homeless Project‘s hostel on Bower Street, was found dead by staff on August 20, 2021.

Staff grew concerned after Mr Chandler had not been seen since the previous evening. After discovering him unconscious they performed CPR but he was certified dead by paramedics at 4.40pm.

Yesterday’s inquest in Northallerton heard Mr Chandler had been homeless “most of his adult life” and was diagnosed with depression and anxiety in 2014.

His GP said he had a history of drug misuse and had been previously referred to substance misuse services in North Yorkshire.

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Coroner John Bainbridge read evidence from the police, which found no signs of a struggle or disturbance.

The police statement added that besides pain relief medication prescribed to Mr Chandler after he broke his leg, there were no other drugs to be found in his room at the hostel.

Mr Bainbridge added Mr Chandler did not leave a note and there was no indication from friends and others living in the hostel that he was thinking of ending his life.

The coroner said he would disregard suicide as a cause of death because there was no evidence to indicate Mr Chandler intended to end his life.

Concluding the inquest, Mr Bainbridge said:

“A toxicology report found a fatal selection of drugs in Mr Chandler’s system that contributed to his death. Therefore I believe it is safe legally and scientifically to make a conclusion that his death was drug related.”