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Inquest touching the death of Nigel Handscomb




The inquest into the death of Nigel Thomas Handscomb has concluded that neglect contributed to his death. Mr Handscomb died on the 21st August 2017 at the age of 65 at University Hospital Lewisham from aspiration pneumonia and bronchopneumonia. 

The Coroner found that there were several missed opportunities with respect to escalating Mr Handscomb’s care in the 48 period following admission. The Coroner recorded that the following were gross failures in providing care:

  • Mr Handscomb was transferred to Laurel Ward, where no observations of him were taken for 11 hours;
  • NEWS scores were recorded as 5 on one occasion, but referral to the outreach team and senior nurse was not made;
  • NEWS scores on subsequent occasions were wrongly recorded;
  • Mr Handscomb was assessed on the ward as being unable to swallow and was subsequently made Nil by Mouth. Consequently, Mr Handscomb’s oral medications were stopped, with no referral made to doctors as a result of omitting his medication;
  • When fluids were prescribed for Mr Handscomb, a doctor seemingly wrote up fluid without reviewing him;
  • At the nursing handovers, staff did not identify that MrHandscomb had not been reviewed by a doctor;
  • Mr Handscomb’s lithium levels were not taken upon his admission to University Hospital Lewisham, nor during his stay, contrary to Trust policy. 

The Coroner recorded that Mr Handscomb died from natural causes to which neglect contributed. 

The Coroner made a Prevention of Future Death report in respect of Mr Handscomb’s GP, Dr Gramsma, as he had significant concerns in respect of his record keeping.  

Dominique Smith acted for the family. 

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