Published: 05:00, 19 October 2021
| Updated: 11:59, 20 October 2021
A support worker died after being allowed to leave hospital while ill and not understanding the consequences of his actions, a court has heard.
An inquest into the death of Craig Phelan heard that staff at the William Harvey Hospital in Ashford failed to assess his capacity, directly leading to his death.
The coroner's court heard that had medical staff carried out a capacity check, they would have found the Dover man lacked the capacity to understand the situation he was in, and would have been legally able to restrain him to give him the treatment he desperately needed.
It also heard that at the time of Mr Phelan's death on May 19, 2020, capacity checks were taken out on less than a third of patients who needed them.
The body of the 34-year-old, who had a history of mental illness and problems with alcohol, was found in a stretch of woodland off Bockham Lane near the hospital after he was allowed to leave in the early hours of that morning.
A post mortem gave his cause of death as alcoholic ketoacidosis, with a background of alcohol related fatty liver disease and early bronchopneumonia.
He was first admitted to hospital when family members called an ambulance after finding him ill and breathing heavily at his home, with what appeared to be vomit mixed with blood in the sink.
However, he left almost immediately after being brought in, with a second ambulance bringing him back after reportedly finding him at a nearby Tesco petrol station.
Upon his second admission, he accepted treatment from doctors before becoming increasingly agitated and demanding to be allowed to go home.
The inquest at County Hall in Maidstone heard that a second doctor, a nurse and two security guards pleaded with Mr Phelan to stay in the hospital, eventually convincing him to go back to his bed.
However, he quickly became agitated again and insisted on leaving, with his nurse and security failing to convince him to stay, and becoming confused over their rights to prevent him from leaving without a formal capacity check.
The court heard that if a capacity check had been taken on the 34-year-old it would have found him lacking capacity, meaning security could have restrained him for his own safety.
Giving evidence, the doctor who first assessed him said that he was "surprised (the patient) was even able to get up", let alone walk out of the hospital unaided.
He also added that if he had remained at the hospital, it was very likely that he would have survived after treatment.
Jason Watson, a representative for East Kent Hospitals Trust which runs the William Harvey, informed the court that an extensive action plan had been carried out in the wake of Mr Phelan's death.
Included in this was an internal audit which found that only 27% of patients who were found to require a capacity check actually had them at the time of the incident.
Mr Watson informed the court that following changes, which included the installation of an electronic system that made it easier for staff to carry out checks, this rate had improved to 81%.
However, in the wake of Mr Phelan's death there were at least two more similar incidents that lead to fatalities, with individual inquests into each incident finding either failings or issues with patient capacity.
One found that Elle Mae Wood was failed by staff at the hospital after being deemed to have capacity to leave the hospital before being struck by a car on the carriageway of the M20 nearby.
In another, Sheila Ratcliffe was found to have 'fluctuating' capacity as she was allowed to leave the A&E ward, with her body being found 12 days later in the same stretch of woodland as Mr Phelan.
Ms Wood and Mrs Ratcliffe died a month and three months after Mr Phelan respectively. The trust's action plan concluded in July of this year.
Assistant Coroner Catherine Wood, who also presided over Elle-Mae Wood's inquest, said that there were failings that contributed directly to the support worker's death, but not severe enough to constitute neglect.
"I accept that there were failings in this case, there was a failing to stop Craig that clearly had significant consequences," she explained.
"The failing appeared to be more on communication between the two (nurses and security guards), I don’t consider that to be a 'gross' or serious failing in the same way that is required to constitute a legal finding of neglect."
Mr Phelan's brother Daniel said that his death had "left a devastating impact" on his family.
"We have been struggling to come to terms with it, and even looking at things as objectively as possible it is hard to get past the fact that had Craig received the proper care, he would have been alive today," he added.
Reading out a statement in court, he said that there were several moments that his brother could have been saved, starting with the decision to not allow a family member to come with him to hospital.
"We feel that one of us should have been allowed to come with him, and we should have been called when he tried to leave the hospital the first time, but we weren't.
"Although nothing can be done to bring Craig back, I sincerely hope that lessons have been learnt by both the medical and security staff in order to prevent a similar incident from happening again."
Summarising, Ms Wood said that she hoped that evidence that things had changed at the trust would provide "some token" of comfort for the family.
"My sincere condolences on your loss, it must have been particularly difficult to hear the evidence we have heard, especially from that first day, knowing that he would have been able to survived had he been stopped from leaving," she said.
"Hopefully you will gain some token of comfort from the fact that some things have changed since then, they (the hospital) have amended some issues.
"It was obvious he was well loved with a supportive family. I do hope you will be able to rebuild your lives."