Coroner rules man, 65, died of pneumonia amid family’s concerns about level of care at Sheffield neuro rehab centre

John Michael Lysak, who had his own fencing business, was working on his own roof with his son on October 1, 2018 when he had a fall.

At an inquest held at Sheffield's Coroner Court on Wednesday, April 27, it heard that John was rushed to Glasgow's intensive care unit, where he was found to have sustained physical and neurological injuries, leaving him in a 'frail' and 'fragile' state.

The Bolton-born man then ended up being cared for at the Stocksbridge Neurological Rehabilitation Centre, before being admitted to the Northern General Hospital on two separate occasions.

On August 5, 2021 he was admitted to the hospital with a high fever and aspiration pneumonia, which was caused by secretions and also the contents from his stomach.

He was further admitted to the same hospital after episodes of seizures, where he was believed to have suffered from sepsis or severe infection, before passing away at Northern General Hospital on September 15.

Throughout his stay at the Sheffield rehabilitation centre, his family expressed concerns about his care, including allegations that the tube attached to John's catheter urine bag was ‘blocked’ due to the possibility that the bag was not changed for a long time.

A witness, Claire Dickson, who works with the NHS as a healthcare assistant and was John's carer, said she noticed that the blockages had happened on ‘several occasions’ during her visits.

This was also raised by the Yorkshire Ambulance Service crew members who attended to John, saying that the bag was full of urine and a considerable amount of sediments.

His son, Daniel also said that there was also a concern regarding his hygiene.

He said: “They weren’t brushing his teeth, (the issue) with the catheter, and the state of his bed. We also got him a brand new telly and it took them six weeks to set it up. A lot of time we could never get through (the phone) as well.”

No evidence of urinary tract infection

But according to a pathologist who testified at the inquest, Dr Panagiota Kitsanta, there was no evidence in the radiology scan that the cause of death was a urinary tract infection.

This was corroborated by consultant Dr Marni Greig that the probable cause of the pneumonia was aspiration.

Stocksbridge Neuro Rehabilitation Centre, Kathryn Sandra Oakley also testified that she had removed the offending bag but saved it to be examined by a GP who attended to John following his seizures.

She also said that John's catheter bag was changed on a daily basis.

In his conclusion, Assistant Coroner Stephen Eccleston said: "The doctors did consider a urinary tract infection but felt on the balance it was probably not that but they nevertheless took a belt and braces approach to John's treatment and a broad range of antibiotics and it was not a urinary tract infection.

"The family felt there were a wide range of issues with the care home and their concerns are justified but for me today, I have to be satisfied that they directly contributed to the cause of death.

"Mrs Oakley said she had personally disconnected the offending urine bag on the day the bag caused the ambulance so much concern and the bag was saved to show the GP and I have to accept that."

He added due to John's fragile and frail state that resulted from his physical and neurological disabilities, he was prone to pneumonia.

He said: "If a strong, fit and healthy person had had this infection, they would have struggled with it too.”

He then concluded the cause of death as 'accidental' and that John had died of aspiration pneumonia consequent to a fall from a roof.

Mr Eccleston also conveyed his condolences to the family, who were present at the inquest and described him as 'hardworking'.

Daniel, said: "He was hardworking. He loved fishing, shooting, watching rugby and football. A huge sports fan. If he was not working he would be shooting or at the golf course."

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