Doctors’ inadequate management of Laura Booth’s feeding at the Royal Hallamshire Hospital, in Sheffield was a “gross failure of her care”, assistant coroner Abigail Combes said, as she concluded that clinicians’ lack of compliance with the Mental Capacity Act was “unlawful”.
Ms Booth’s parents, Patricia and Ken Booth, told the inquest in Sheffield how doctors ignored their daughter and excluded them from decision-making after the 21-year-old was admitted in September 2016.
The couple, from Sheffield, received an apology from the coroner for having to fight for an inquest into their daughter’s death on October 19 2016.
On Monday, Ms Combes ruled: “On the basis of the evidence I have heard and on the balance of probabilities, I am satisfied that the decision not to adequately manage Laura’s nutrition was a gross failure of her care.”
In a narrative conclusion, Ms Combes said: “Among other illnesses, she also developed malnutrition due to inadequate management of her nutritional needs. Her death was contributed to by neglect.”
Ms Combes concluded that the hospital had acted “unlawfully” in the decisions it made about Ms Booth’s feeding, and said she had “significant concern” about senior doctors’ understanding of the Mental Capacity Act.
She said: “Where I do remain gravely concerned is in the hospital’s approach to the Mental Capacity Act and those individuals who do not have capacity to make decisions for themselves.”
The coroner said she felt Ms Booth’s parents, Patricia and Ken Booth, were “overburdened and undervalued” by the hospital and “at the same time they were completely excluded from decisions, if indeed there were decisions, made about Laura nutritional status during her admission”.
Ms Combes said she would give up her own time, if necessary, to help train staff at the hospital in how to lawfully come to decisions in relation to people without capacity to do so for themselves.
Turning to Mr and Mrs Booth, who were watching proceedings remotely from their home, she also apologised for failings in the coronial service which left them having to fight for an inquest.
The coroner said she would be writing to the chief coroner to urge better training for coroners on the Mental Capacity Act and Liberty Protection Safeguards.
Ms Combes said she was “going to be bold” and invite Mr and Mrs Booth to help her draft these recommendations.
She told the couple: “Probably the hardest but most important bit, Mr and Mrs Booth, is to try and put into words the admiration I have got for you.”
Ms Combes said Mr and Mrs Booth were completely devoted to their daughter “who lived her life to the full”.
At the beginning of the two-week long inquest at Sheffield Town Hall, Mrs Booth said doctors ignored her “lovely, kind, caring” daughter, despite her being able to communicate to some extent, including using Makaton signing.
Mrs Booth told the inquest: “They never discussed anything with Laura.
“They just ignored her.
“She couldn’t speak but she could understand everything.”
Mrs Booth described how, after she was born, Ms Booth was diagnosed with partial trisomy 13 and had a number of different life-limiting complications, including learning disabilities.