Coroner finds Chesterfield Royal Hospital security staff at fault in 85-year-old man's death - due to fractures after being restrained

Les Wallage, a retired groundworker and lifelong Chesterfield resident, was 85 years old when he was admitted to hospital on June 20, 2017, to have a catheter fitted. He was due home the same day, but never returned and was followed to the grave a few weeks later by Jean, his heartbroken wife of 63 years.

Delivering his final verdict a few weeks ago, senior coroner Peter Nieto said that although Les had severe pre-existing health conditions, “Right arm fracture and shoulder dislocation, sustained in hospital, made a more than minimal contribution to his death because of the likely detrimental effect on his overall clinical condition and reduced physical reserve.

“It is unlikely that the injuries would have occurred if full account had been taken of his confused and agitated state.”

Les’s sister, Christine Sears, now 76 and the last living of six siblings, says she may never feel a sense of closure due to the manner of his death, but was determined to see the hospital held to account so that other patients might avoid a similar fate.

Christine, who lives in Holymoorside and was walked down the aisle by Les at her wedding, said: “I just can’t believe he went like that. I know he was old and he’d got things wrong with him, but he still had a good quality of life.

“We were very close. We went up to their house almost every day. He did everything for Jean physically, and she looked after him mentally. He still enjoyed spending time with his dog, feeding the birds and sitting in the garden. Simple things made him happy. His life was of value.

“He should have been with his wife. All their lives were spent together, they were inseparable, and for it to end like that is just wrong. He didn’t deserve to die like that. Nobody should die like that.”

She added: “I know people look at the dead with rose-tinted glasses but I could never find anything bad to say about him. There were no bad memories. We loved him and wanted justice for him. I wanted to find out who was responsible and make sure everyone knew what had happened.

“We were told early on by lawyers and the Crown Prosecution Service that the coroner probably wouldn’t place any blame on the hospital – and their lawyer argued that right to the end – but he has, and I think it’s absolutely the right decision."

An investigation carried out by the hospital acknowledged a number of failings identified early on by the family, both in the lead up to Les’s injury and the aftermath.

After being admitted to the Emergency Department on referral from his GP, a consultant raised concerns about Les’s condition and it was decided he should remain in the Emergency Medical Unit overnight.

His admission notes recorded that Les had “some cognitive impairment [and] required regular reassurance and reorientation as to where he was.” He scored four out of ten on a cognitive function test, indicating possible dementia, but his mental state was not documented in his nursing evaluation or communicated to the nurse in charge of his care.

Kept in for a second night in hospital, at 11pm on June 21 Les was said to be settled well, though he “regularly asked about his wife as he was anxious she was being cared for at home.”

Sometime soon after that, Les was transferred to an overspill ward which had been set up that afternoon under the supervision of an agency nurse.

The staff nurse who had been responsible for Les’s care told investigators “she didn’t feel that the patient was a suitable patient to transfer … due to requiring regular reorientation to his surroundings.

“The nurse-in-charge stated that as the patient was documented as being settled and scheduled to be discharged the following day it was decided he would be suitable to transfer.”

The ward was not prepared for patients when Les transferred, “which could have impacted on the patient’s confusional state.” The ward lights were off, his bed was the only one made, and the room was cluttered with equipment kept there for storage.

While one staff statement described Les as “settled on transfer”, another said he was “clearly disorientated and delirious.”

Accounts further diverge on what happened next, but according to one witness at around 1.30am Les was found in a staff-only room adjacent to the ward, apparently looking for a way out.

The report states he was holding a glass vase and threatening to “smash the vase in their faces” if staff approached him.

A healthcare assistant later said: “The patient was clearly distressed and disorientated continuingly stating he wanted to go home.”

The coroner concurred, saying: “The aggressive and threatening behaviour exhibited by Les immediately prior to his injury was the product of his confused state and anxiety over his wife's welfare and was totally out of character.”

According to Christine: “They all kept calling him John, which was his legal name but no one else had used it for years. He wouldn’t have known who they were talking to.”

The confrontation continued as Les continued attempting to leave the ward. Still holding the vase, he is said to have thrown a fire extinguisher at nursing staff, so they called for emergency security support.

Two officers arrived on the scene, first distracting Les, then taking hold of his wrist, causing the vase to smash on the floor.

Both officers told the investigation that “when they were restraining the patient in the standing position the patient was actively struggling against them attempting to free himself, this involved him kicking at the legs of the security officers.”

What happened next was crucial, but again accounts differ over a matter of seconds.

According to the investigation report, “The patient suffered a shoulder injury due to the security officers losing their grip of the patient’s shoulders during an attempt to restrain him by placing him on the floor.”

Early in the inquest, the testimony of one witness convinced the coroner to adjourn proceedings and refer the case to the Crown Prosecution Service for possible criminal charges. The CPS ultimately decided there was no realistic prospect of securing a conviction due to conflicting witness evidence.

The report notes that the two security officers, employed by private contractor VSG, took control of the incident, contrary to hospital policy which requires “physical restraint techniques as directed by medical/nursing staff.”

It had been six years since one of the officers attended ‘annual’ refresher training in control and restraint techniques, and three years for the other.

According to the hospital report, “restraining patients by placing them on the floor in the prone position, is … used as a last resort by the security officers within the trust.

“The amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood of seriousness of harm.”

While Les was said to calm almost immediately after being returned to his bed, he complained of pain in his arm and was taken for X-rays in the early hours which confirmed the fracture and dislocation.

The hospital report notes that as Les appeared too confused to consent to surgery under general anaesthetic, doctors took that decision for him.

All this time, Jean was bedbound in the couple’s home, seriously ill with bowel cancer, so Christine’s name had been given to the hospital as the person to call in the event of any problem.

Despite that, the next morning the hospital did place their first call to Jean to explain what had happened and offer an apology, causing her great distress.

Christine said: “Jean rang us crying, then we had to ring the hospital. I was ill that day, so my husband, Malcolm, went straight up there and said it was just heartbreaking.

“Les only weighed about nine stone, he probably had dementia, and after that he was a shadow of his former self. I couldn’t believe the state of his body. His arm was so bruised and swollen that his skin was leaking. He couldn’t walk, and he thought he could see Jean in the room. It was horrendous to see the change.”

Though the surgery on his arm and shoulder was initially successful, Les’s overall health deteriorated over the following days in hospital and ongoing periods of agitation and confusion – or delirium, as doctors described it – meant he did not always comply the post-operative care instructions to help heal his wounds.

In the same period, the hospital investigation notes instances where staff did not follow expected procedures for assessing and recording Les’s condition, or escalate his care when necessary.

On July 3, Les was reported to have died in the early hours, discovered during a routine welfare check by a nurse who had heard him make “a funny noise” or “audible breathing sounds” a short time earlier but chose to finish treating another patient rather than immediately attending to him.

A post mortem determined the cause of death was bronchopneumonia due to pulmonary emphysema and cancer of the prostate, and though the pathologist noted the injury to Les’s arm they concluded it was not a causal factor in his death.

Christine said: “I’d seen him the day before. I tried to feed him a bit of food and combed his hair. We had a chat and he told me to stop making a fuss. He said he was tired but he didn’t want me to leave.

“I could tell there was something wrong with his chest, and asked the nurse if he was on something strong for it, but they were just giving him paracetamol. They never told us he had pneumonia.”

The family say that other indications from hospital staff over the years have painted a picture that is even harder to take in.

Tracy said: “Les died alone, asking for someone to hold his hand and no one came.”

That was the news that Christine broke to Jean – the tragic final note of a marriage that had held strong through the hardship of losing their only child at six weeks old and several failed pregnancies after.

Christine said: “It was horrendous. She just stopped eating and kept saying she wanted Les. She died within a few weeks at Ashgate Hospice. At least she was looked after. It was a better end than he had. They’re buried together at Clay Cross. That’s all we could do for them.”

As a result of its investigation, Chesterfield Royal produced a number of recommendations to improve procedures for transferring patients between wards, monitor the storage of items such as glass vases and clarify the responsibilities of security and nursing staff when managing challenging behaviour in vulnerable adults.

Other areas identified for improvement included training at the hospital and third party providers, information supplied to families on patients’ condition and handover protocols between clinical staff.

VSG employees working at Chesterfield Royal were transferred to its in-house security company Derbyshire Support and Facilities Services Limited (DSFS) when that was created in 2019.

A spokesperson for the Chesterfield Royal Hospital NHS Foundation Trust declined to say whether those officers involved were still employed at the hospital, citing a duty of care to its staff.

VSG was sold by parent company Compass Group in 2018. They declined to comment when asked by the Derbyshire Times about any internal lessons drawn from the incident.

Dr Hal Spencer, chief executive of Chesterfield Royal Hospital, said: “We share our condolences with the family of Mr Wallage and those affected by his loss. We have worked with HM Coroner throughout the inquest proceedings and will respect his findings.

“Since the death of Mr Wallage we have completed a thorough review of training and processes, including with our DSFS colleagues, and these findings have now been implemented across our wards and areas.”

As Christine reflects on the final outcome, she hopes she will make peace with it all in time and that sharing his story might help that process.

She said: “It’s gone on a long time, and the hospital say they have made changes since. I just hope some good has come from it. That’s all I can say.

“If anyone else has an elderly relative go into hospital, keep a close eye on them. We thought he was safe but you’ve got to be on the ball all the time.

“And let them know they are loved, that they are a person who’s cared about, they’re never just a confused elderly person.”

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