AN elderly former RAF sergeant was left without enough food or water in hospital after being pushed to the ground by a fellow care home resident, an inquest into his death has heard.
Douglas Arthur Davies – known as Doug – was born in Liverpool and travelled the world before settling in Jersey and working in insurance. He had three children with his late wife Jean.
An inquest into the death of the 95-year-old heard yesterday that Mr Davies was a quiet but “popular” resident at Lakeside Manor Care Home, who suffered from complex health issues in his later years.
CCTV from 29 August 2023 showed how another patient was in the care home lobby when Mr Davies walked past him.
The other patient got up and pushed Mr Davies with both hands – with no apparent provocation, and no previous conflict between them – and he fell to the ground, breaking the neck of his femur.
Mr Davies was taken to the Emergency Department and had hip replacement surgery – but in the following days, his condition deteriorated.
A postmortem report found that, in the days that followed, Mr Davies was not given enough nutrition or hydration whilst in the General Hospital.
Dr Simon Chapman, chief of surgical services, said this would have affected his recovery but would not have caused his death.
The postmortem found an “unbroken link between the incident and his death”, noting that the complications “would not have arisen” without him being pushed and falling.
Mr Davies was pronounced dead on the morning of 4 September 2023.
A police investigation was carried out, alongside a serious incident investigation at the Hospital.
Criminal charges were not pursued against the patient who pushed Mr Davies due to their cognitive impairment, described as “delirium”.
Health’s serious incident report found that Mr Davies “did not receive adequate hydration or nutrition to support his healing or recovery from surgery”.
The inquest also heard that the patient who pushed Mr Davies had previously been violent towards staff and patients.
Lakeside Manor Care Home registered manager Rosie Goulding said that notice had been given for the patient to leave the care home out of concern for the safety of other residents.
However, a shortage of adequate beds in the Island meant no new placement was found.
And a misunderstanding between mental health services and the care home meant that support workers stopped looking for an alternative placement while the care home staff still believed they were searching for a bed.
Deputy Viscount Advocate Matt Berry, sitting as coroner, said that this referral process “could be looked at” due to the risk of misunderstanding.
After the incident, the patient involved was assessed under the Mental Health Law and placed in a specialised ward.
Advocate Berry found that Mr Davies had died of multiple organ failure after hip replacement surgery, contributed to by dementia and old age.
He extended his condolences to Mr Davies’s family, who said in a statement that they were “extremely proud” and “grateful” for the 95-year-old.
Simon West, Medical Director for Health and Care Jersey, offered his “deepest sympathies to Mr Davies’ family” on behalf of the department.
“In the event of an unexpected patient death in our care, Health and Care Jersey undertakes a full and detailed review to identify any learning that may help prevent similar occurrences in the future,” he explained.
Mr West confirmed that “several measures” had been implemented following this case, reassuring Islanders that the Health is “firmly committed to the continuous enhancement of patient care”.
“We also continue to strengthen our approach to supporting patients’ hydration and nutritional needs as a fundamental part of safe and compassionate care across all our services,” he added.
The Jersey Care Commission confirmed it had initiated its regulatory processes as a result of the incident, and had worked closely with stakeholders to support a “full and transparent understanding of the circumstances”.
“The Commission extends its sincere condolences to the family and loved ones of the resident whose death is the subject of the inquest,” a spokesperson added.
