A disabled and non-verbal man, 22, from Sheffield, died after his observations were taken just once in 12 hours.

Darnell Smith had sickle cell disease for which he received regular treatment, and cerebral palsy. Darnell lacked mental capacity and was completely dependent on others for his daily needs and medical care. He was cared for at home by mum Leila and dad Errol.

They took Darnell to Royal Hallamshire Hospital with a suspected sickle cell crisis, which is a complication where the blood flow is blocked due to cells becoming stuck in a blood vessel and a possible respiratory tract infection.

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Darnell’s condition deteriorated and around 12 hours after Darnell was admitted, he was moved to the critical care unit and placed in an induced coma. He also underwent a blood transfusion.

Tragically, just 16 days after he was admitted Darnell lost his battle and died aged 22 and now a coroner has called on health bosses to take action to prevent future deaths of a similar nature.

Following their son’s death, Leila, 45, and Errol, 44, instructed expert medical negligence lawyers at Irwin Mitchell to support the family through an inquest and secure answers.

An inquest earlier this month found that following Darnell’s admission to hospital, his observations were carried out at 2.16am and not repeated again until more than 12 hours later. ­This was despite Darnell having an individualised care plan which set out observations should be conducted hourly for a minimum of six hours.

The inquest was told that Darnell’s health passport was not in his records and was not available to staff until more than eight-and-a-half hours after his admission.

Darnell and his mum Leila
Darnell and his mum Leila

Recording a narrative conclusion, senior coroner Tanyka Rawden, told the court that Darnell’s observations being taken once in 12 hours amounted to “gross failings in care”. She did not record a neglect finding as the coroner was unable to say whether Darnell’s death could have been prevented had appropriate observations been undertaken.

However, the coroner has now issued a Prevention For Future Deaths report saying there was a “missed opportunity” to identify Darnell’s condition was deteriorating. She has called on Royal Hallamshire Hospital to set out what measures it will take to improve care.

The coroner said that despite a warning ‘flag’ being present on computerised records alerting staff to Darnell’s individualised care plan, it was hard to locate in the records, and was not considered during his admission.

She added that “individualised care plans are crucial to a patient’s care and it is my view that without knowledge or sight of them by treating clinicians there is a real risk of further deaths.”

The coroner’s report comes after an internal investigation report from Sheffield Teaching Hospitals NHS Foundation Trust, which runs Royal Hallamshire Hospital, also found that during the first 12 hours of Darnell’s admission, nursing staff only obtained his observations once, around one hour after he was admitted on to the ward. This was due to “communication lapses” between staff members not knowing where to find his sickle cell care plan, and also between staff members and Darnell’s family, for which the Trust apologised.

It also identified “several opportunities” where communication could be improved. It recommended the implementation of a training package for sickle cell disease and a steering group for shared learning around complex patients.

Sinead Rollinson-Hayes, the specialist medical negligence and inquest lawyer at Irwin Mitchell representing the family, said after the hearing: “The past 15 months have been incredibly difficult for Leila and Errol, who understandably remain devastated by their son’s death and the circumstances surrounding it.

“Their grieving has been all the harder due to the number of questions and concerns they had regarding Darnell’s care. While nothing will ever make up for the pain and loss Leila and Errol suffer, the inquest has been a major milestone in being able to provide them with the vital answers they deserve.

“Sadly, the investigation report and inquest both identified worrying issues in the care provided to Darnell. Patients who lack capacity are society’s most vulnerable and can’t speak up for themselves. Therefore, it’s vital that medical staff take all steps possible to ensure they communicate between themselves and with loved ones to ensure a patient’s care needs are met.

“While we welcome recommendations in the Hospital Trust’s own report to implement additional staff training around sickle cell disease and patients lacking capacity, it’s vital these are implemented and staff are supported to ensure these are upheld at all times. We continue to support Leila and Errol at this distressing time.”

Darnell was admitted to hospital on 7 November, 2022, at around 1am. His observations were recorded at around 2.16am. They were due to be repeated hourly for the first six hours, in line with his individualised sickle cell care plan. However, this wasn’t undertaken.

Staff hadn’t taken further observations and bloods were not escalated to the senior sister on duty. The Hospital Trust’s investigation report stated that if it had been, senior medical staff could have intervened and assessed Darnell, who was non-verbal, at an earlier stage.

This didn’t happen however, and at around 2pm Leila sought out a sickle cell specialist consultant. The Hospital Trust’s report said the consultant attended the ward around 2.30pm and felt Darnell had “deteriorated significantly.”

He was suspected to be suffering from possible acute chest syndrome – an illness in sickle cell disease which can progress rapidly – and possible sepsis – when the body attacks itself in response to infection. Darnell was transferred to the intensive care unit, where he died days later.

The inquest also heard that Darnell had an individualised care plan for sickle cell disease but this was not followed when he was cared for on the ward. Had his observations been recorded in accordance with this plan, Darnell’s deterioration may have been picked up sooner.

After the hearing Leila and Errol said: “To this day, we still can’t accept that Darnell’s not here anymore. He was our beloved boy and our lives were dedicated to looking after him. There’s not a day goes by when we don’t miss him.

“It feels like time has stood still since we lost Darnell, particularly because we had so many questions over what happened. The inquest has been really tough but at least we now have some answers.

“Sickle cell disease is a complex condition and we feel like there’s still not enough known about it and how to care for someone living with it, particularly those who also have learning difficulties like Darnell did.

“And while we know that nothing will ever bring Darnell back, we just hope that his death isn’t in vain and medical staff will endeavour to undertake the training required to help improve patient safety for those with sickle cell disease.”

Darnell also leaves behind three sisters, one who also has sickle cell disease and is currently receiving treatment for this.

The family are keen to help raise awareness about sickle cell disease and the impact it has on those affected. More information can be found on the Sickle Cell Charity website at www.sicklecellsociety.org.

Since Darnell’s death, the NHS Trust has made a number of changes with an aim of improving care for patients like Darnell. However, the coroner stated she remained concerned about the availability of individualised care plans and health passports to staff. The inquest heard that alerts are being added to the new electronic system, but it was pointed out by the coroner that there was no guarantee these would be clearly visible and wouldn’t be missed. As a result, she advised she would write a Prevention For Future Deaths Report to ensure this was taken into account.

The Coroner also said she will write to the NHS Trust in six months for an update on improvements required around the standard of documentation kept and future audits on this.

Leila and Errol were represented by Irwin Mitchell on a pro-bono basis at the inquest. Through pro bono work, the company provides free legal advice and representation to those who otherwise can’t afford access to justice.

Dr Jennifer Hill, Medical Director, Sheffield Teaching Hospitals NHS Foundation Trust, said: “I would like to apologise again that we did not carry out Darnell’s observations as frequently as we should have done, and that his individualised care plan was not immediately visible to staff.

“I know that we cannot take away the pain that Darnell’s family are feeling, but I hope that I can reassure them that we have learnt from this and are taking actions to limit the chances of this happening again. We are implementing a new electronic patient care record system this year which will make all of our patients records more readily accessible for staff to take into account when delivering care.”

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