Failings by doctors led to ‘shocking and unacceptable’ death of rough sleeper, inquest finds

Failings and ‘negligent communication’ by several doctors and nurses contributed to the ‘shocking and unacceptable’ death of a vulnerable Wexham Park Hospital patient, an inquest has found.

Wayne Merchant died aged 51 as a result of a perforated ulcer after being ‘unsafely’ and ‘inappropriately’ discharged from the hospital.

An inquest into his death spanning five days heard from four doctors, six other clinicians, three members of senior management, Slough council and police. It concluded on Tuesday (September 9).

Mr Merchant, who was a rough sleeper, was admitted to Wexham Park Hospital on May 15, 2023, after being found at a petrol station with abdominal pain and in poor health.

He had not eaten for 10 days and was significantly malnourished.

Mr Merchant had previously made multiple suicide attempts, including one which was two days prior to his admittance to hospital.

Slough Borough Council had already taken an interest in his welfare – Mr Merchant had been referred to the adults safeguarding team due to his suicide attempts and self-neglect.

A vulnerable and ‘complex’ patient

Once in hospital, Mr Merchant was ‘irritable, angry and agitated,’ shouting and being abusive towards staff.

He kept claiming there was nothing wrong with him and he wanted to leave.

Mr Merchant was non-compliant with his treatment and deeply distrustful of the clinicians – he accused them of poisoning him and described them as ‘evil’.

At times he was ‘not speaking much sense’ and his behaviour was ‘challenging and downright disturbing.’

This gave rise to suspicions that Mr Merchant had significant mental health problems which might have meant he lacked the capacity to make decisions about his own care.

Indeed, an assessment led to Mr Merchant being placed on a psychiatric hold, whereby security would have prevented him from leaving the hospital if he tried.

Despite this, after four days in hospital, Mr Merchant was discharged. But he should not have been, the inquest determined. Largely, this was down to communication failures.

There was a sense, said coroner Hannah Godfrey, that clinicians kept assuming that someone more senior knew better and was taking charge.

Failures of communication

One of the most senior people involved was Mr Ihsan Al-Shoek, a consultant general surgeon at Wexham Park. His particular errors came heavily under the spotlight at the inquest.

Ms Godfrey said he took only a ‘cursory’ look at Mr Merchant’s medical notes, as he was looking for a specific piece of information, and spoke to his patient for only a few minutes.

During that time, Mr Merchant ‘seemed calm’ and, as his physical state had improved with the aid of some treatments. Mr Al-Shoek therefore felt he could discharge him from hospital.

However, crucially, Mr Al-Shoek missed the part of Mr Merchant’s notes which detailed his mental health problems and reduced capacity.

“He said he failed to pick up at all that there were any mental health or capacity issues,” said Ms Godfrey.

Mr Al-Shoek had ‘relied on a consultant to flag up anything important’ – but this hadn’t happened.

Ms Godfrey said Mr Al-Shoek had ‘relied entirely’ on a much less experienced, foundation-year doctor – Dr Junzheng Wang – who had been in post for less than a year.

She said that, while she appreciated that doctors are busy people and do not have time to read all patient notes, Mr Merchant’s mental health problems were ‘heavily labelled’ with brightly coloured tabs and other markers.

“I find it impossible that any decent look [at Mr Merchant’s notes] wouldn’t show he was vulnerable and had capacity issues,” Ms Godfrey said.

Mr Al-Shoek accepted that, had it not been for the gaps in his knowledge, he would not have discharged his patient.

He and Frimley NHS Trust, which runs Wexham Park Hospital, both accepted the premature discharge from hospital contributed ‘more than minimally’ to Mr Merchant’s death.

Failures during discharge

There were also ‘a number of missed opportunities’ surrounding the discharge process itself.

Given that Mr Merchant was a rough sleeper who Slough council had raised concerns about, the hospital should have known whose care he was being discharged to, Ms Godfrey said.

But nurse Rolando Ong, who was in charge of the ward and held responsibility for discharges, had not looked into this properly.

He consequently discharged Mr Merchant ‘into a potentially unsafe environment’, Ms Godfrey said – and she criticised Mr Ong’s ‘lack of professional curiosity’ here.

“Any one of these missed opportunities, [if they had not been missed], would have averted this unsafe discharge… [and given Mr Merchant] a significant chance of survival,” said Ms Godfrey.

Mr Ong did not give evidence directly at the inquest and is now outside the jurisdiction of the court, which means there are certain claims he made that couldn’t be challenged.

One was his claim that he was unaware of Mr Merchant’s mental health problems. The fact that he instructed for razors to be removed from Mr Merchant’s room throws doubt on this, Ms Godfrey said.

Conclusions

However, despite failings from a ‘range’ of clinical staff, there were no ‘structural or systemic failings’ at the hospital, she said.

As such, she did not return a conclusion of corporate manslaughter, even though the circumstances around Mr Merchant’s death are ‘obviously shocking and unacceptable.’

Frimley ran its own ‘considerable’ investigation and had already taken steps to address the issues by the time of the inquest, making changes to its policies and stepping up its awareness training.

Because of this, Ms Godfrey does not feel there is any ‘continuous risk of death’ at Wexham Park.

She also determined that no one member of staff met the threshold for gross negligence manslaughter.

Nor could she class Mr Merchant’s treatment as ‘neglect’ in law. This would entail a ‘gross absence of care’ rather than simply providing the wrong care.

“There might be negligence [here] but it does not amount to neglect,” said Ms Godfrey.

However, Mr Merchant’s death does amount to a ‘gross failure of basic medicine’ – ie, a significant lapse in fundamental medical care that results in preventable harm or death.

She said that Mr Al-Shoek, as a leading physician, should have done better and his failure to notice the mental health reports were ‘not a proper excuse’.

“He barely looked at Mr Merchant’s records at all,” said Ms Godfrey.

Mr Merchant died on May 23, four days after he was discharged from the hospital, and was found in a field adjacent to the Colnbrook bypass.

His family described him as a ‘free spirit’ who found relief from his mental health struggles in his passion for sport, which was ‘his great escape.’

Ms Godfrey said she hoped Mr Merchant’s family could take some solace in the fact that Wexham Park has taken steps to improve.

“Wayne Merchant’s death has made a difference – there has been learning from it,” she said.