Rachel Johnston

Rachel’s story

Rachel was a 49 year old lady who had a learning disability after after contracting meningitis as a baby. She lived in a care home, and underwent dental surgery at Kidderminster Hospital in 2018 following severe tooth decay.

As Rachel lacked capacity, medical professionals should have consulted with her family, particularly her mother Diana, before making decisions regarding Rachel’s treatment. Doctors in Rachel's case were expected to take into account her mother's concerns when making treatment decisions. Diana was responsible for giving that input and doctors should have discussed treatment options with her.

Instead, there was little to no discussion with her family about any alternative courses of treatment, nor were her family made aware of risks of the procedure or the risks associated with general anaesthetic. Against her family’s wishes, medical professionals made the decision to remove all 19 of Rachel’s teeth, and to undertake the procedure under general anaesthetic without checking whether she had previously suffered a reaction to the medication.  

After the surgery, Rachel was discharged straight back to her care home, instead of being monitored in hospital overnight. It was there where Rachel’s condition declined, and staff at the care home did not adequately provide her with the basic medical care that she needed. She was bleeding; had difficulty breathing; and was asleep for 42 hours before staff sought emergency treatment for her. By the time an ambulance was called, her brain had been starved of oxygen and she had developed aspiration pneumonia.

By the time she arrived at the hospital, the staff advised Rachel’s family that the brain injuries that she had sustained were unsurvivable. Diana and her family bravely took the decision to take Rachel off life support and she passed away of her injuries two weeks later.

The Inquest

After receiving this case through the Mencap Helpline, Caron Heyes of Fieldfisher took this case on pro bono.

The inquest heard how the nurses at the care home failed to recognise that she was dangerously ill, take basic medical observations and failed to take notes of her deterioration. The doctor who reviewed her care said that the care she had received at the home could only be described as gross failures. It was revealed that the nurses who cared for Rachel had been allowed to keep working at the care home, as the home manager felt that it was better for the other residents to be cared for by staff they knew and did not believe that the other residents would be at risk.

Furthermore, when care home staff called 111 the day before she was admitted to hospital, the call handler failed to ask direct questions about Rachel’s condition. Expert evidence revealed that if she was taken in for emergency care following this call, it was likely that she would have survived.

At the conclusion of the Inquest the Coroner delivered a narrative verdict and held that Rachel had died of a hypoxic brain injury, and that her death had been contributed to by a gross failing to provide basic care which amounted to neglect.

After delivering the verdict the Coroner also issued a Preventing Future Death Report following hearing additional evidence from the Interested Parties about what changes had been made to prevent a death like Rachel’s happening again. As he said when issuing his Report, he was not satisfied that enough had been done to prevent a future death in respect of the changes by the Care Home.

The PFD report noted his concerns about the care home’s lack of internal investigation and disciplinary procedure despite a clear gross failings by the nurses to care for Rachel. The inquest had heard that nurses had continued to work at the home for some time without procedures put in place to ensure safety of other residents. The home had also made no conduct report to the body who regulates their conduct for over two years.

The Coroner also criticised the care home for failing to have clear policies and procedures for investigating misconduct by staff, imposing suspensions pending investigations and, in the event of misconduct, preventing staff from working there in the future and reporting them to the regulatory authority.

What can be learned?

Families are too often not consulted when a loved one with a learning disability is receiving medical treatment. When speaking to the press, Rachel’s mother Diana said that families are sidelined by professionals time and time again - even when they clearly know the person best and love them the most. Diane said that the inquest and the coroner’s investigation had allowed for justice, and that she was relieved that the nurses had since been reported to the Nursing and Midwifery Council for poor standards of practice and were finally no longer being employed (through an agency) by the Care Home.

“nothing can bring Rachel back, but at least we can go forwards knowing her death has not been ignored”.

Diane Johnston

Caron Heyes, who represented Diana at the inquest,

[Mencap - Dan?] said that this case demonstrates…..

It was Rachel’s and Diana’s experiences which spurred the evolution of this project, which operates to act as a voice to speak out about healthcare inequality issues that affect people with a learning disability.