The inquest into the death of Dan Dryden, a 32-year-old man, concluded on Friday 14th October 2022. The final inquest was held over 9 days before HM Area Coroner for Leicester City and South Leicestershire Mr Ivan Cartwright.
Dan sadly died on 28th August 2018 after sustaining a head injury and subsequent cardiac arrest while a patient at the Agnes Unit in Leicester.
The medical cause of death was recorded as:
1a Positional Asphyxia
1b Head Injury
The Coroner recorded a narrative conclusion, recording that Dan was a voluntary patient at the Agnes Unit and was under staff observations at all times. He was found lying on his front on the floor of his bedroom unresponsive on the morning of 28th August 2018 at 09:37 hours. He was last visited by staff at 09:20 hours and had been heard and was understood to have been breathing heavily. Resuscitation attempts were made at the Unit and Dan was transferred to Leicester Royal Infirmary, where his death was confirmed later the same morning.
The Coroner recorded a missed opportunity by the Trust that ran the Unit, either by the earlier summoning of paramedic emergency services and/or by effecting a more timely, earlier transfer to hospital, which may have altered the outcome for Dan.
The inquest explored the following areas:
1. Why Dan was admitted to the Agnes Unit;
2. What care was provided in relation to possible head injuries sustained during Dan’s time on the Agnes Unit;
3. What were the level of observations and were these correctly implemented;
4. What physical checks were carried out, including observations and neuro-observations;
5. What was the level/availability of physical health checks, training and knowledge of the staff caring for Dan;
6. What was the care plan, did this change and was it correctly implemented; and
7. What was the cause of death.
Evidence was heard from a number of witnesses who were responsible for Dan’s care on the Unit, as well as experts instructed by the Area Coroner, including an expert Psychiatrist, Neurologist and Neurosurgeon.
Following the witness evidence, the Coroner made findings that Dan had developed a presentation that raised concerns which led to his informal admission to Agnes Unit on 24th August 2018. Over the following days, Dan continued to deteriorate with increasing confusion and agitation. On the day before and the day of his death, Dan suffered multiple head impacts and sustained serious traumatic brain injury as a result of a single impact or the cumulative impact. There was concern around his presentation on 28th August 2018 and the Coroner found that the neurological observations had not taken place since 26th August 2018 and the physical observations had not taken place as often as they should have.
The Coroner found a failure at 09:20 on 28th August 2018, when Dan was being assisted to a sitting position and given medication, to investigate the condition and also a failure to monitor Dan more closely after 09:20. Dan was later judged to be asleep and the Coroner found that it should have been clear that Dan should have been watched more carefully and should have been placed in the recovery position. The Coroner heard evidence from Professor Green that it is clear that, on the balance of probabilities, that earlier intervention would have resulted in a better outcome for Dan.
Dan’s family said:
Dan went into the Agnes unit for a medication review with devastating results. We assumed that he would have been safe and cared for adequately, but this was clearly not the case.
This has been a long painful journey that no other family should have to experience.