Terence Talbot
3 Dec 2021 · Coroner Sonia Hayes · Mid Kent and Medway
The coroner's concerns
1. life-threatening reaction to prescription medication
“Evidence was heard at the Inquest that Mr [name redacted] suffered an exceptionally rare life- threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis”
2. lack of mental capacity assessments
“There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment”
3. inadequate nutrition and fluid intake
“Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February”
4. lack of dermatology review and emollient application
“absence of regular dermatology review and lack of application of emollients.”
5. mandatory in-person benefit claim for severely ill inpatient
“The Department of Work & Pensions required [the deceased] to attend in person to make a claim for benefits rather than accept an electronic claim”