Missed opportunities before ex-footballer's death

An inquest jury has found missed opportunities contributed to the death of former footballer Colin Flatt, who had Alzheimer's disease.

The ex-Southend and Cambridge United player seriously injured himself and fell from height at Basildon Hospital in July 2021. He later developed an infection and died that September.

His former partner, Melanie Leahy, who campaigned for the Lampard Inquiry into mental health deaths in Essex, said she did not want to hear that "lessons had been learnt" but wanted to know "who would take responsibility".

Mid and South Essex NHS Foundation Trust (MSEFT) said it had already changed how patients at risk of delirium or confusion are monitored.

During the two-week inquest, the 81-year-old, who also played for Leyton Orient, Wisbech and St Albans, had been described as a fit and active man who enjoyed golf, walking his dog and sailing before his dementia worsened.

The 10-member jury at the hearing in Chelmsford concluded there had been several missed opportunities to assess Flatt's mental capacity and the risk of him leaving care settings unsupervised and coming to harm.

Jurors found one missed opportunity occurred when a mental health tribunal approved his discharge from Goodmayes Hospital in Ilford in June 2021, after he had been detained under the Mental Health Act.

They said his release led to an "unsettled period", during which he moved between care settings and his own home while becoming increasingly confused and aggressive.

The jury also identified failures including the lack of a referral to a specialist mental health team and a failure to complete a handover when he was admitted to Basildon Hospital from a care home.

They said there was an absence of risk assessments for him leaving care, and shortcomings in handovers when he was transferred between wards.

The inquest heard Flatt was admitted to Basildon Hospital with heart issues.

Once medically fit for discharge, staff struggled to complete a full assessment because of his agitated behaviour. The inquest heard there were a limited number of security guards at the hospital who were not trained in restraining patients.

On 27 July 2021, Flatt took a pair of scissors being used to cut another patient's hair, and stabbed himself in the abdomen. He then left the ward area and climbed over a landing before falling about five metres.

The jury concluded the probable cause of death was the self-inflicted injury, the fall and a subsequent infection.

Dr Fitzpatrick, a cardiac pathologist described his medical cause of death as an acute infection of the lungs, damage to the lungs and an enlarged heart.

Leahy said: "To see him deteriorate so rapidly under supposed professional care is something I will never recover from."

Christine Blanshard, chief medical officer at MSEFT, said: "We offer our sincerest condolences to Colin's family and loved ones.

"We have worked to address the recommendations made following an independent investigation last year. All the actions have been completed, and learning has been shared across the trust."

Blanshard said changes had included tighter medicines management, improved observation of patients at risk of delirium or acute mental health crises, better record keeping and information sharing, and reducing unnecessary ward moves.

Essex Partnership University NHS Foundation Trust and Essex County Council have been approached for comment.

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