Coroner finds mental health patient’s death preventable

A coroner has stated that a mental health facility might have averted the demise of a man who passed away following his refusal of both treatment and sustenance. Kevin Ince had been held under the Mental Health Act at Kemple View Hospital, located in Langho, Blackburn, during the previous year. An inquest determined that the 55-year-old individual succumbed to heart failure, which was connected to lung injuries attributed to vaping, on 25 October 2023, at the Royal Blackburn Hospital. Christopher Long, the area coroner, indicated that The Priory Group, the operator of the 90-bed Kemple View mental health unit, failed to adequately encourage Mr Ince to accept the necessary medical treatment for his condition. Mr Long, who serves as the area coroner for Lancashire and Blackburn with Darwen, has issued a report aimed at preventing future deaths. Within this report, he highlighted concerns regarding evidence of Mr Ince’s “regular refusals of necessary and appropriate medical treatment” and “insufficient action taken when he routinely declined food over a prolonged period” during his detention under the Mental Health Act 1983. The coroner noted that Mr Ince activated a call bell to inform Kemple View staff of his ill health on 24 October 2023. Personnel observed that he was experiencing shortness of breath and panting, and oxygen was provided until the arrival of an ambulance. Mr Ince was transported to Royal Blackburn Hospital, where he continued to receive oxygen support. While hospitalized, he underwent various diagnostic procedures, but his health worsened, and he did not recover. Mr Long stated that Mr Ince’s death resulted from heart failure, connected to lung injuries stemming from the use of e-cigarettes, also known as vapes. Mr Long commented: “During the course of the inquest the evidence revealed matters giving rise to concern. “In my opinion there is a risk that future deaths could occur unless action is taken.” A representative for the hospital stated: “We would like to reiterate our sincere condolences to Mr Ince’s family for their loss. “We strive to support patients in the least restrictive way possible, in line with the statutory framework. This includes enabling patients to maintain their independence and make informed decisions for themselves, including on issues such as dietary preferences or vaping, as an integral part of good mental healthcare. “In light of this case, we reviewed and enhanced our processes to provide increased support for staff in their documented approach when a patient declines physical health checks and a nutritional diet, whilst carefully balancing this complex area.” The Priory Group is required to submit a response to Mr Long’s report by 14 January 2025. This response must detail any actions taken or planned, or provide a justification for not proposing any action. Additionally, the report has been dispatched to Mr Ince’s family, Sabden and Whalley Medical Group, and the Care Quality Commission (CQC).