An assistant coroner amended the cause of death of a young disabled woman after deciding she did not receive adequate nutrition during her time in hospital for a routine operation.
After hearing the case of Laura Booth, Abigail Combes also said she would write to the chief coroner with the suggestion that coroners are routinely trained on the principles of the Mental Capacity Act.
Various media outlets reported the inquest into the death of Laura, 21, who was admitted to the Royal Hallamshire hospital in Sheffield in September 2016 for a routine eye operation and died the following month.
The inquest heard that Laura had a number of learning difficulties and life-limiting complications, having been diagnosed with partial trisomy 13, a rare genetic disorder, shortly after she was born.
Her mother, Patricia Booth, told the inquest that her daughter stopped eating shortly after she was admitted to hospital, and that doctors ignored Laura’s attempts to communicate with them.
She said her daughter consumed only rice milk and blackcurrant juice in hospital, and she kept telling doctors: “This isn’t right, she can’t survive on no food.”
The assistant coroner concluded that Laura became unwell while a patient at the hospital and, among other illnesses, “developed malnutrition due to inadequate management for her nutritional needs”. She ruled that Laura’s death “was contributed to by neglect”.
Ms Combes said that although Laura’s medical records indicated that nutritional intake was a “concern from her admission” to hospital, feeding charts were not established.
She said: “I am satisfied on the balance of probabilities that had Laura received adequate nutrition during her admission, the outcome on the 19 October 2016 would have been altered.”
She also apologised to Laura’s parents for the “concerted” effort they had had to make to get a full inquest.
The family told the media that Laura was a “much-loved and longed-for daughter who completed our family” and had “brought so much joy to our lives”.
They added: “No one seems to understand that the risks of not feeding Laura meant that she was starving as she died in front of us. We cannot tell you how painful that is to live with.
“This has to stop. It’s not right that learning disabled people die decades prematurely. It’s not right that Laura was malnourished. We also don’t think it’s right that the only reason Laura’s inquest was opened was because a journalist contacted the coroner. How many other people are dying without anyone ever finding out why?”
Kirsten Major, the chief executive of Sheffield teaching hospitals NHS foundation trust, said: “We regret what happened and we have already overhauled our nutrition service and processes so there is now a clear lead decision-maker to review and expedite actions for patients with complex nutritional needs. We are truly sorry for what happened, and we will be responding to all of the coroner’s recommendations to prevent this situation happening again.”
