Trust fined for failures in care of dementia patient who died after absconding

An NHS trust has been fined for a “catalogue of failures” which saw a dementia patient abscond from a hospital three times and die after hitting his head on concrete.

Peter Mullis, who had advanced dementia, left Queen’s Hospital in Burton upon Trent, Staffordshire, twice in the space of a few hours before the fatal incident on July 15 2019.

After running out of the hospital, he climbed over a barrier and fell down a grass embankment, and the 77-year-old died of multiple traumatic injuries, prosecutor Ayman Khokhar told a hearing at Southern Derbyshire Magistrates’ Court in Derby on Monday

University Hospitals of Derby and Burton (UHDB) NHS Trust, which manages the centre, was fined £200,000 after it pleaded guilty to being a care provider that exposed a patient to a significant risk of avoidable harm, in its first criminal prosecution.

Mr Khokhar, prosecuting on behalf of the Care Quality Commission, said Mr Mullis was transferred to the hospital after becoming unresponsive at his specialist care home on July 14 2019.

He was known to have a “propensity to abscond from clinical environments” and had been described by health staff as an “escape artist”, absconding from different wards twice at the hospital before the fatal incident.

Mr Khokhar said: “At around 2pm (on July 15), the deceased left the ward for a third time.

“Two nurses ran after him. Unfortunately, seeing the nurses run towards him, the deceased decided to run down the corridor to the exit.

“Once outside, the deceased stopped running. He threatened to punch the staff if they came near him.

“Unfortunately the deceased continued to metal barriers that were approximately three feet in height. The nurse asked him to come back.

“In response, he shouted ‘stay away or I will hurt you’. He then climbed over a barrier which was at the top of a sloping embankment.

“He shouted ‘you’re not going to stop me’ and began to descend down the slope.

“As he approached the bottom of the slope, he lost his balance and fell on to the pavement. That produced an audible crack.”

Mr Mullis, a horticulturist from Burton, was flown by air ambulance to Royal Stoke University Hospital but died later that day.

Mr Khokhar said that the CQC believed there was a “catalogue of failures” which contributed to Mr Mullis’s “avoidable death”, including insufficient staff training and limited policies on how to deal with missing patients.

In a statement read out by Mr Khokhar, Mr Mullis’s daughter, Selina Kendrick, said “inadequate levels of training” had contributed to her father’s death.

She said: “It was a complete shock. We had plans and how quickly they changed is unbearable.

“I feel I have been robbed of getting to know my dad again.

“It was basic safeguarding.”

Eleanor Sanderson, mitigating, said the care given to Mr Mullis was “not a wholesale failure” and there was a low likelihood of death in the circumstances, but acknowledged that policies were not followed and steps had been taken to ensure such an incident did not happen again.

She added: “It is correct that at the heart of the guilty plea is a failure to carry out the correct procedure laid down by the policy.

“Those who were treating him were endeavouring to assess him and contribute to his needs.

“It is understood by the trust that the practice of undertaking (risk assessments) was not embedded enough.”

Handing down the sentence, which could have been an unlimited fine, District Judge Jonathan Taaffe said: “I have considerable sympathy for the hard-working and valued staff of the trust, who I believe did their best to cope with the difficulties posed by Mr Mullis and his advanced dementia in the pressurised situation of the hospital.

“Robust procedures that were in place were not adhered to sufficiently.

“I also note that the trust is a publicly funded body that does not operate for gain or profit. Any fine will divert funds away from frontline services.”

As well as the fine, the trust was also ordered to pay costs of £16,483.88 and a victim surcharge of £181.

After the hearing, Garry Marsh, executive chief nurse for the trust, said: “We remain incredibly sorry for what happened to Mr Mullis, and our sincere condolences continue to be with his family.

“Mr Mullis was supervised during his time in our care, but it is clear that improvements were needed to how some of our policies, there to keep people like Mr Mullis safe, were put into practice and we fully accept the CQC’s findings.

“Since this sad incident in 2018, we have created a dedicated Mental Capacity Act education team to better support and train our staff, and introduced a new auditing process to track compliance against best practice.

“We remain absolutely committed to improving further to ensure that we provide the safest care and treatment to all patients in our care.”