Coroner slams Royal London Hospital after drug addict's death
PUBLISHED: 09:10 26 April 2019
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A coroner has criticised the Royal London Hospital after a patient's body went undiscovered beneath a pile of clothes.
Dawn Gill was a long-term drug addict who died of a methadone overdose after taking illicit substances on top of prescribed medication while being treated at the Royal London in Whitechapel.
The 33-year-old was seen by staff between midnight and 12.30am on June 2 last year then checked on at intervals but it wasn't until 10am that she was found dead.
St Pancras coroner Mary Hassell has issued a prevention of future deaths report following Ms Gill's inquest.
The report raises four concerns. It states Ms Gill was likely to take drugs whether in or out of hospital but that while she was at the Royal London no care plan was in place to take the increased risk into account.
The report adds although Ms Gill was prescribed methadone and died after overdosing on it, her drug chart was not available at inquest and appeared to have been lost.
It states that if the drug chart was lost when she was alive, then that has implications for her care, but if it went missing afterwards, it left the trust open to an accusation of trying to cover up evidence.
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“Whenever it was lost, its absence is very disappointing,” the report states.
The Royal London's legal representative at the inquest also didn't know the chart was missing until the coroner asked for it.
Ms Hassell heard Ms Gill wasn't present during searches of her room, but CCTV footage proved she was.
It was also believed Ms Gill popped out for a cigarette before 12.30am but she wasn't seen leaving.
However, even though it turned out she hadn't left the ward, hospital security wasn't told, which might have led them to review the CCTV helping them realise Ms Gill had not gone.
There 'seemed to be a lack of clarity' about what steps to follow when someone goes missing, the report says.
A Barts Health NHS Trust spokeswoman said: “This was a tragic event and we apologise that Ms Gill's body was not found sooner.
“All nursing staff involved have been reminded of the importance of following trust procedures and to document the suspected use of illicit drugs in care plans.
“We can confirm the correct dose of methadone was administered as prescribed. While we have not been able to locate the medicine prescribing chart, the risk of this happening in future is minimised by our plans to move to electronic prescribing.”