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A hospital 'refused to readmit' a sick man despite being told his Sittingbourne home was unfit to live in, a coroner report states.
Christopher Smith, 63, was left in an ‘unclean’ Williams Street property despite having no bed and exposed electrics, the findings suggest.
Mr Smith was eventually found by his family without access to food or drink. He had been discharged from Medway Maritime Hospital, Gillingham, without proper care plans and no arrangements made for a district nurse to visit him to treat his leg ulcers.
Transport staff who took him home raised serious hygiene and health and safety concerns, a report to prevent future deaths states.
Staff said they were instructed not to return Mr Smith to hospital as there was no bed available, so they raised a safeguarding alert, the report states.
Now the chain of events which led to Mr Smith’s death has led to Sonia Hayes, assistant coroner for Mid Kent and Medway, raising concerns with the chief executive of Medway NHS Foundation Trust, which runs the hospital, and the head of adult safeguarding at Kent County Council.
Ms Hayes conducted an inquest into Mr Smith’s death in July last year but has now sent a Prevention of Future Deaths report to the two authorities and to the Chief Coroner.
At the inquest she recorded a narrative conclusion in which she stated that Mr Smith died at the hospital on March 4, 2019, of pneumonia with abscesses due to ulceration.
Mr Smith was admitted in January 2019 with a history of vascular disease, extensive leg ulcers and epilepsy.
He was found not to have the capacity for his treatment and so a deprivation of liberty (DOL) authorization was sought.
During his stay in hospital his condition deteriorated and he remained confused. But the inquest heard that he was discharged in February “without appropriate discharge planning”.
Mr Smith’s family found him on the floor with no leg dressings, unable to move and with no access to food or drink. Mr Smith was readmitted but his condition deteriorated and he died on March 4.
In her report Ms Hayes adds: “In my opinion there is a risk that future deaths could occur unless action is taken.”
The authorities have until March 31 to respond.
Dr David Sulch, medical director at the hospital trust said: “We deeply regret the circumstances surrounding Mr Smith’s death. "The Trust at no point refused to provide further care to Mr Smith; we will never refuse a bed when needed.”
He said transport staff were advised to take Mr Smith to A&E if they felt it was necessary.
The Trust said it will "carefully consider" the report before responding to the coroner.