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Inquest clarifies failings in care prior to death of Jesse Rollason

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Medical law experts at Shoosmiths Solicitors have attended an inquest on 30 March 2021 into the death of Jesse Rollason (88) who died on 10 April 2020 at Sandwell and West Birmingham Hospitals NHS Trust.

Mr Rollason’s son, Michael, explained that despite his age his father led an active life living in his own home in the months prior to his death. He was a fiercely independent 88-year-old retired production foreman at the former Rover factory in Longbridge, who had raised his own family alone having been widowed since 1976.

On 24 March 2020 Mr Rollason was admitted to City Hospital because of some shortness of breath. A chest x-ray revealed that there was no acute pneumonia, but he was given antibiotics for a suspected chest infection. 3 days later a test confirmed that he had COVID-19. However, by 31 March 2020 he was considered medically fit to be discharged home from hospital care.

Delays in provision of PPE to social services led to transfer to Ward D47

Because of the requirement for Mr Rollason to self-isolate for ten days at home following his hospital discharge, a referral to social services was undertaken to assist him with his day to day needs. Unfortunately, due to a delay in social services receiving the necessary personal protective equipment (PPE), they were unable to attend Mr Rollason at his home and alternative arrangements were made for him to be transferred from the acute medical unit to Ward D47 at City Hospital to support his needs and await his transport home after the PPE had been delivered.

During Mr Rollason’s four-day social admission to Ward D47, the inquest heard that the family being prevented from visiting him at the hospital, remained in regular contact with their father through telephone calls and by using facetime. They became increasingly concerned about his declining condition and repeatedly raised concerns with nursing staff on the telephone about their father’s poor fluid and dietary intake which they had observed.

Family concerns not acted upon

Despite the family raising the alarm, Mr Rollason went on to deteriorate and he subsequently collapsed in the early hours of 4 April 2020. Unfortunately, his condition continued to worsen that day and following a 999 call he was re-admitted by ambulance to the Accident and Emergency Department at City Hospital in the late afternoon. Five hours later a do-not-resuscitate order was put into place and Mr Rollason proceeded to receive palliative care.

Over the following week Mr Rollason’s condition deteriorated further and he suffered renal failure and a suspected deep vein thrombosis. Following his subsequent transfer to Leasowes Intermediate Care Centre, Mr Rollason sadly died on 10 April 2020, this being the day his self-isolation was supposed to have ended.

Internal investigation confirms failings in care

An investigation report was compiled by Sandwell and West Birmingham Hospitals NHS Trust following Mr Rollason’s death. This confirmed that there had been failings on the part of the nursing staff to monitor Mr Rollason’s fluid intake and that had the appropriate charts been completed this may have highlighted the need for an earlier response to Mr Rollason’s dehydration and declining condition. It was also admitted that during this ward admission staff had failed to take into account the concerns raised by the family.

The report highlighted a number of remedial actions to improve services at the hospital Trust, which included:

  • The need for all nursing documentation for admission and stay on D47 to be reviewed and audited by the matron
  • The need for supervision and standards of care to be reviewed for all nursing staff to ensure best practice
  • The need for nursing staff to receive training on recognition of the deteriorating and dying patient

The inquest heard evidence from the matron covering Ward D47 that staff should have acted sooner when Mr Rollason showed signs of deterioration. However, two clinicians at the Trust were of the view that Mr Rollason’s deterioration was due to COVID-19 and that even if he had received earlier treatment, it was unlikely he would have survived this multi-system disease.

HM Coroner’s conclusion

HM Coroner, Mrs Louise Hunt, concluded that Mr Rollason’s death was from natural causes as a consequence of COVID-19.

Victoria Blankstone, an expert medical negligence lawyer at Shoosmiths Solicitors Birmingham office, said:

“The family have been devastated by the death of their father and have struggled to come to terms with his unexpected loss after what they understood to have been a successful recovery from a possible chest infection. The inquest has been an extremely difficult time for the family, but they are satisfied that an investigation of their father’s death has been carried out and that they now have further answers about the events that resulted in his deterioration with such a tragic outcome. We are pleased that the Trust have taken early steps to admit that the care Mr Rollason received on D47 fell below a reasonable standard and have apologised to the family.”

Mr Rollason’s son, Michael, added:

“Our father held a very high place in our family’s lives and it has been difficult not to feel bitter or angry about what happened, particularly when my father had been declared medically fit to return to his home and continue living his independent and active life. It is a tragedy that his initial successful recovery and discharge from medical care then seemed to go so disastrously wrong when there was a shortage of PPE and he couldn’t get home.”

Victoria concluded:

“Nothing can turn the clocks back, but it gives the family some peace of mind to know from the inquest that they were right to bring matters to the attention of the Coroner and that the admitted shortcomings in Mr Rollason’s care on Ward D47 have led to lessons being learned to prevent similar incidents being repeated and to protect the future care of patients.”

Jesse Rollason

Pictured above: Jesse Rollason.

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