Hospital staff knocked on door of toilet where patient lay dead for two days
A hospital security guard and several cleaners knocked on the locked door of a disabled toilet where a patient lay dead or dying from a drugs overdose – but when they got no reply they did nothing, an inquest heard today.
A guard was actively searching for Mr Earp, 32, who had been reported missing from his ward at Gloucestershire Royal Hospital in the early hours of 8th July.
But when he got no response from the locked toilet he just carried on his search, the Gloucester inquest was told.
Over the ensuing two days several cleaning staff found the toilet locked and got no response to their knocking either – but no more was said or done by them.
It was only when Mr Earp had been missing for nearly two and a half days that the toilet was entered after reports of a smell coming from the cubicle.
Mr Earp’s decomposing body was found on the toilet floor.
A pathologist estimated he had been dead for at least 36 hours by the time he was found. His death was due to a cocktail of drugs, many prescribed but also including illicit cocaine and alcohol.
The inquest heard that even the fact that Mr Earp had been found collapsed in the same toilets twice in the two days before his death did not trigger any extra concerns when he went missing the third time.
After today’s inquest, Gloucestershire Royal Hospital issued a statement saying it has ‘reviewed and strengthened’ its communication systems and procedures in the light of the tragedy.
The assistant Gloucestershire coroner Caroline Saunders recorded a conclusion that Mr Earp, of Gloucester, suffered a ‘drug related death.’
"Unfortunately no attempt was made to enter those toilets but that should have occurred," she said.
"If the search had been adequate he would have been discovered earlier. No further searches were made.
"I am of the opinion that there have been omissions in this case. In relation to the search, I am of course concerned about how that was managed on the night of 7/8 July.
"I believe there were missed opportunities to discover him earlier and he would have been discovered earlier if the search had been adequate.
"However, I cannot say that if he had been found earlier his death would have been prevented.
"I have been reassured today that policies have been tightened and a ‘dynamic log’ has now been adopted by hospital security and the porterage staff. "
Mr Earp had been admitted to ward 4A of the hospital on July 5 with thigh pains which were thought to be due to a deep vein thrombosis.
He constantly complained he was not getting enough painkiller medication – and he repeatedly left the ward saying he was going out for a cigarette to clear his head, the inquest was told.
He threatened to discharge himself but doctors managed to persuade him he should stay because his life was at risk from a blood clot forming in his lungs.
The inquest heard that on July 6 he left the ward and was found collapsed in the disabled toilets on the ground floor. The same happened the following morning, 7th July.
But when he walked out at 10.55pm on the night of July 7 his absence was not reported for more than four hours.
Peter Scarrott, the facilities general manager at the hospital, said there was just one security guard on duty and he was asked at 3am to look for Mr Earp.
He could have alerted porters to join in the search if he considered it necessary.
However, the guard insisted he had not been given any information about Mr Earp having already been found collapsed twice in the toilets, said Mr Scarrott.
Within 30 minutes the guard reported that he had searched all the areas of the hospital where Mr Earp could be and had not found him. This would have included five publicly accessible toilets, he said.
"When he arrived at that toilet (the one where Mr Earp was later found) the door was locked. He knocked on the door but received no reply.
"He assumed someone was in there using it and he carried on his search.
"One of the lessons we have learned is that irrespective whether it is day or night if a toilet door is locked and we knock on it and get no response we then ask to have it opened."
The coroner asked if the hospital protocol contained no requirement for that toilet to be checked again later. Mr Scarrott said there should have been but the security guard did not inform anyone that he had found a cubicle locked and that he got no reply.
"The only person who knew about that toilet was this single security guard," he said.
The hospital now had a document to improve search procedures and to continue them till a missing patient is found, he added.
If a similar missing person search was initiated now, porters would also automatically become involved, he said.
He went on to reveal that over the weekend of 8/9 July ‘several domestics attended the disabled toilet to clean it.’
He said "The knocked the door, received no reply and carried on. Now, they are told that if they knock a door and they go back for the next clean and it is still locked they are to call portering services for it to be opened."
He said a new system was being trialled whereby notices are placed on toilet doors saying when they were last cleaned and logging if they were locked when a cleaner tried to get in. "
The coroner said she was concerned not just about the failure to find Mr Earp more quickly but also whether he had been given too much Fentanyl in the ward. Fentanyl is a strong pain killing drug administered by patches.
Mr Earp appeared to have been given more than was prescribed for him but the coroner heard that he complained he had lost some because of sweating so there was no clear evidence that he had been overdosed.
However, she said, she was not happy with documentation about the administration of Fentanyl patches or whether old ones were recovered before new ones were applied.
She would be issuing a ‘Prevention of Further Deaths’ report to the hospital to ensure Fentanyl patches were better managed, she said.
In a statement to the inquest Detective Sgt Tristram Jones said Mr Earp was found lying face down on the toilet floor in a pool of blood and fluid.
Tinfoil drug wraps were around him. His body was in a state of putrefaction.
Pathologist Dr John McCarthy said Mr Earp was a drug addict who had been treated with numerous medications and had suffered deep vein thromboses and pulmonary embolisms in the past.
The doctor found many drugs present in the body – including morphine, diazepam, Zopiclone, alcohol and cocaine. He gave the cause of death as the combined toxic effects of all the drugs.
He estimated that Mr Earp had been dead for at least 36 hours before his body was found.
The inquest heard Mr Earp had needed strong pain killing treatment since 2000 when he injured his back in a road accident. The injury had troubled him all his life.
He had suffered two previous blood clots in the legs and one in the lungs in the past.
The Ward 4A manager at the time, Matthew Little, said "On July 7 he left the ward at 10.55pm. He was noted to be agitated before leaving the ward.
He said he was being lied to and he didn’t know why he was in hospital. He said he needed a cigarette to calm him down.
"I would expect staff to keep an eye on the time for 45 minutes and to check if he is not back."
The coroner pointed out it was 3am before the alarm was raised and asked Mr Little to comment on that.
He said "I would expect staff to go and have a look. Go down to the front desk and see if he is out there having a cigarette."
The nurse looking after Mr Earp at the time he went missing was not aware of the two previous collapses in the toilet, he said.
He would have expected that to be discussed at the nursing shift handovers, he said, and he was surprised it had not been.
Members of Mr Earp’s family attended the inquest and left without making any comment.
Gloucesteshire Royal Hospital NHS Foundation Trust said "Our thoughts and sincere sympathies are with Jonathan Earp’s family following his tragic and untimely death.
"The circumstances leading up to the death of Mr Earp were fully explored by the Coroner during the inquest today.
"Following Mr Earp’s death last summer, we carried out a wide-reaching and detailed investigation into the care we provided. This rare occurrence was distressing for everyone involved and we offer our deepest condolences to his family.
"We accept that Mr Earp’s death highlighted gaps in our communication and procedures for dealing with unauthorised absences from our wards – these have subsequently been reviewed and strengthened in a number of ways.
"We are now working to ensure that changes resulting from Mr Earp’s death are embedded into our current practice."
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