An independent NHS investigation has found a vulnerable man detained for 10 years was thwarted by a system to care for him.
Clive Tracy, a man who spent his life in the care of NHS and social care officials, experienced an “unacceptably poor quality of life”, and did not keep him safe from harm before his death at only 47 years of age had gone.
independent review findings, Granthshala And Sky News could reveal, concluding that Mr Tracy’s death was “potentially avoidable” and comes after years of his family “fighting” for answers.
His family is now conducting a second investigation into his death as the review found that guidelines on a pathological report and post-mortem used by coroners were not followed, along with new CCTV footage from the night he died. .
NHS England launched the review in January 2020 under the Learning Disability Mortality Review Programme – three years after Mr Tracy’s death and his family were initially denied the review.
in an exclusive interview with GranthshalaElaine Clark, Mr. Tracy’s sister, said: “Two words connect our beloved son and brother – hope and family. Clive was our world, and we were his, he was the best of us all and he brought magic, joy, Tried to keep the fun.
“We’ve fought because Clive deserved no less. He spent his entire life in prison, and so did we, his entire family. He didn’t care. His voice didn’t matter. His human rights didn’t matter. His life choices didn’t matter. The system and its people believed that he didn’t matter and that no one had ambitions to do anything different.
“Okay Clive spoke. It matters what happened to him. It matters that it’s still happening to other people. And it matters that nothing’s changing, we’re a family.” But there are many others like us.
the review Mr Tracy’s care and death followed a series of shocking reports into poor care of people with learning disabilities and came a decade after the Winterbourne View scandal, which exposed the horrific abuse of vulnerable people with an inpatient unit .
no life outside the hospital
Mr Tracy had a learning disability and suffered from a complex epileptic syndrome called Leonard Gastott syndrome. He was first admitted to an inpatient unit in 2007.
The review commented, “The physicians overseeing Clive’s inpatient care did not see life outside the hospital as an alternative to Clive and failed to pursue a timely discharge for him.”
The review noted that this “institutionalisation” further distanced him from his intended life and resulted in “unnecessarily prolonged” detention in hospital.
Mr Tracy remained “in captivity” in places that could not meet the needs and before his death was eventually held at Cedar Vale Hospital where he was placed “at high risk of sudden death”.
NHS commissioners have been criticized for placing Mr Tracy in units such as Cedar Vale, where his “epilepsy care overall was far less than acceptable practice for someone with complex incurable epilepsy”.
Throughout his life, the review found that Mr Tracy faced health disparities as health professionals attributed his health needs solely to his epilepsy.
‘I knew he was dying’
In the last months of his life Mr Tracy was a patient at a hospital called Cedar Vale, now operated by Signet Healthcare – but then owned by Danshell Group – responsible for the 2018 Whorlton Hall scandal.
The unit was formally owned by Castlebeck Care, which was responsible for the Winterbourne View scandal, which saw people with learning disabilities subjected to horrific abuse.
An investigation into his care at Cedar Vale found that staff had not been trained in epilepsy care and that the hospital did not provide him with access to the breathing equipment he needed at night.
On the night of his death, the staff’s emergency response was described as “limited, confused and chaotic” and may have reduced his chances of survival.
Ms Clarke described how she knew he was dying in the weeks and days following his death.
She said, “We knew he was dying, and no one listened to us, there was a very obvious decline in Clive’s ability to function. Clive, he kept telling everyone, was not well.
“I can’t describe the feeling of knowing that he was dying. But no one cared, despite all my efforts to seek, cure and raise concerns for life and my fears all along. Just him and me Was sacked and my parents were just fired.”
In April 2017 a coroner concluded that Mr Tracy had died of “natural causes”.
However, the NHS report found evidence that an erroneous pathology and post-mortem report was used during the investigation, which did not comply with national guidelines from the Royal College of Pathologists and that Mr Tracy’s risk of ‘sudden unexpected death in epilepsy’ did not take into account. ,
According to the report the attorney general wrote to the review chair, Ms Dawkins, warning that coroners’ decisions can only be reviewed by high courts and that “coroners and jurors cannot engage in public debate about their decisions. “
The review noted that failures revealed in the pathologist’s report and failure to care for his epilepsy may constitute “new information” for requesting a second investigation.
sexual abuse allegations
During his early 20s, while caring for an adult care home between 1989 and 1993, Mr. Tracy was subjected to sexual abuse by a staff member.
The charges were never properly pursued by any authority, despite having left the house after the abuse was reported to Cheshire Police, Staffordshire County Council and East Cheshire Council. The perpetrator allegedly gained access to Mr Tracy in a second residential house.
Reviewers found that the security response to the alleged sexual abuse failed to protect Mr Tracy and recommended local authorities review all sexual abuse allegations received during this period.
Other key findings and recommendations
- The response by the NHS, council and police to the family’s concerns and subsequent investigation into his death was inadequate.
- Efforts to discharge Mr Tracy from the hospital were “thwarted” by financial and systemic hurdles from health and care commissioners.
- NHS England directors should address concerns and engage with the chief coroner on the work-around to prevent future deaths of people with learning disabilities
- NHS England should review the local capacity of the NHS to provide safe care for people with learning disabilities who have complex needs
- National Institute for Clinical Excellence to review guidelines for the care of people with epilepsy and learning disabilities
- Health Education England and the Medical Royal Colleges should train to highlight issues of clinical overshadowing, while hospitals, GPs and NHS England should raise awareness
A spokesperson for Cygnet Health Care said: “At the time of Mr. Tracy’s death in 2017, Cedar Vale was not owned or operated by Cygnet Health Care. Although we did not have service as of August 2018, more than a year and a half ago Following this, we have worked closely with all concerned to support this review and address any outstanding issues and areas for improvement surrounding his tragic death, and we will continue to share the lessons learned.”
Credit: www.independent.co.uk /