Terence Tuttle

9 Aug 2021 · Coroner Yvonne Blake · Norfolk

The coroner's concerns

1. lack of proper dietician assessment and mental health review
“Lack of proper dietician assessment and mental health review at an early stage”
2. inadequate response to weight loss despite recorded intake
“Inaction when Mr [name redacted] was losing weight even though his intake was recorded no-one acted upon this”
3. inadequate mental capacity assessment
“Ability to assess Mr [name redacted] adequately under the Mental Capacity Act”
4. inadequate care for mentally ill patient with physical health issues
“Inability to care for a mentally unwell patient with physical health problems, including gastric problems, who is refusing to eat”
5. exclusion of family from patient care
“Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation”
6. failure to recognise serious harm
“Apparent lack of recognition that serious harm did occur for this patient who was described as appearing cachexic”