Full jury findings – Anthony Raymond Dawson
This week the inquest into Anthony Dawson concluded in Woking. Anthony’s sister, Julia, wishes for people to know what happened to Anthony. Anthony was being ‘cared’ for by Surrey and Borders Partnership NHS Foundation Trust. You can read the BBC article about the inquest and hear from Julia here. The jury’s determination follows:
Inquest into the death of Anthony Raymond DAWSON deceased
Following the inquest heard before Mr Darren Stewart sitting with a jury at HM Coroners Court, Surrey and concluded on 02 October 2017, the following statutory determinations and findings were made:
Medical cause of death:
1a Gastric Haemorrhage
1b Bleeding Gastric Ulcer
Mr Anthony Raymond Dawson was pronounced dead at 16:47 on the 16th May 2015 in the dining room of Ashmount House, Epsom, Surrey by the attending paramedics.
His death was contributed to by ongoing inadequate care due to insufficient staffing numbers and some inexperienced staff who had little or no clear directives in how to deal with an emergency. One to one care was not provided for Mr Dawson although the funding was in place. There was a lack of adherence to the care plan and risk assessments which were out of date and communication between staff was poor.
Medical checks were not carried out, medical and dental appointments not attended.
This was despite the fact that concerns were raised and requests made by family and professionals.
Had Mr Dawson received medical attention earlier from a doctor it is probable the outcome would have been different.
When help was sought there was insufficient information passed during the telephone call between the care home and the doctor on Saturday 16th May 2015.
We find there was a gross failure in both the decision by the care home not to call a GP on the morning of Saturday 16th May 2015 and the passage of information between the care home and the doctor during the telephone call conducted on Saturday 16th May 2015.
Considering all these factors the jury concludes that the cause of death was contributed to by neglect.