Vulnerable woman starved to death in NHS hospital following ‘unacceptable’ failures

“Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned.

A second inquest into the death of a 45-year-old woman, Jennifer Lewis, has found that the mental health hospital to which she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition.

Mental health charity Rethink has called for improvements to physical healthcare for patients with severe mental illness, whose physical needs they say are “all too often ignored”, while experts at think tank the Centre for Mental Health have warned that patients with mental illness are dying too young as the system “still separates mental and physical health”.

Ms Lewis died in July 2017 from the effects of malnutrition while she was an inpatient at the Bracton Hospital, run by Oxleas Foundation Trust.

Her family have had to fight for a second inquest, which concluded on 8 November, after coroners initially failed to consider negligence on the part of the hospital.

Ms Lewis had a long-term diagnosis of schizophrenia. Her family described how she had lived a full life, completed a degree, and given lectures about living with mental illness. However, after undergoing bariatric surgery, against the wishes of her family, her mental state declined and she was admitted to the Bracton Centre, run by Oxleas, in 2014.

In an interview with The independent, her sister, Angela, described how, in the year before her death, Ms Lewis lost her hair, suffered from diarrhoea, and developed sores on her legs as she effectively “starved to death” from malnutrition.

According to evidence heard at the second inquest, Whittington Hospital had provided Oxleas with dietary information as Ms Lewis needed a high-protein diet.

However, while she was an inpatient at the Bracton Centre, Ms Lewis did not receive the correct diet. Instead she was allowed “three sandwiches” or six slices of bread a day, which was contrary to dietary recommendations for patients who had undergone bariatric surgery, her family have said.

Ms Lewis’s family were told by the hospital that she chose the food she ate, however her family argue that the trust has never provided evidence of mental health capacity assessments it said were carried out.

Ms Lewis’s sister told The Independent that in the year leading up to her death, when the family warned doctors she was “starving to death”, their concerns were dismissed and they were told that the hospital “will not let it come to that”.

She described how, prior to her death, Ms Lewis suffered hair loss to the point where she was “practically bald”, her periods stopped, her eyesight deteriorated, and she suffered from swelling of her legs caused by severe protein deficiency. Because of the extent of the swelling, Ms Lewis’s skin “split”, which resulted in sores.

Her sister added: “Jennifer had diarrhoea, which is a side effect of malnutrition, and she was too weak to go to the toilet or to clean herself up, so the faecal matter entered the open sores in her legs. As a consequence, when she died, she had septicaemia.

“The last time I saw Jennifer at the Bracton Centre, it was really hard to look at her because she was in such a woeful state. The sores on her legs were weeping, and she was shuffling like a 90-year-old, with dirty bandages hanging from her legs.

“Before she got ill, Jennifer was always immaculately turned out. She was tall and willowy. Jennifer loved clothes, loved to look good, hair and nails done, and to see what happened to her was really hard. If Jennifer from 2007 could have seen herself before she died, she would have been absolutely horrified.”

Ms Lewis’s family have also raised serious concerns over the electro-convulsive therapy given to her several months before she died. They said they were told the treatment would make her more “compliant” with her care regime. However, they noted that her “word-finding skills and thinking skills significantly deteriorated” after she was given the treatment.

Angela Lewis described how Oxleas and other hospitals, including the Whittington Hospital, would deal with either Jennifer’s physical health needs or her mental health needs, but rarely with both in conjunction.

She said: “Patients on a psychiatric ward are not one-dimensional. They may arrive on acute mental health wards with any manner of physical health problems. To neglect the holistic needs of the most vulnerable patients who are detained by the state is totally unacceptable to us as a family.

“Jennifer was not responsible for her own care, by virtue of the fact that she was detained under section three of the Mental Health Act. So, to make Jennifer responsible and to blame her for her own death is wholly unethical. We still cannot fully believe that Jennifer was allowed to starve to death whilst in the care of the state.”

Failures to address the physical health of people with severe mental illness have been raised by coroners previously. In one example last year, a coroner in London found that an acute hospital had failed to treat a man’s spinal injury as his symptoms were mistaken for mental health difficulties.

Alexa Knight, associate director for policy and practice at Rethink, told The Independent: “Jennifer Lewis’s death is a tragic example of the consequences when the physical health needs of people living with severe mental illness are neglected. Our thoughts and condolences are with Jennifer’s family.

“The physical health needs of people living with mental illness are all too often ignored. Whether people are receiving inpatient care or living independently, it’s unacceptable that people severely affected by mental illness are more likely to face reduced life expectancy compared to the general population.”

She said that physical health checks can help identify and manage risks to health, but the number of people receiving this service in the community is well below target, so efforts must be made to improve access.

In a statement to The Independent, Andy Bell, deputy chief executive at the Centre for Mental Health, said: “People living with mental health difficulties die too soon, most often because of untreated or poorly treated physical health problems. It’s vital that anyone being treated for a mental health condition gets effective physical healthcare, too.

“This means being seen as a whole person and having all of their health needs taken equally seriously. Tragically people are dying too young when their needs are not properly met by a system that still separates mental and physical health when they are so closely connected.”

Oxleas Foundation Trust was approached for comment.