Open verdict in "gentle giant" inquest

10:56am Sunday 18th May 2008

A coroner says there were shortcomings in the care of a Pembrokeshire mental health patient who died after being sedated, but he won't bring those deficiencies to the attention of the Home Office because the health trust has implemented improvements in the nine years since the man's death.

John Owen recorded an open verdict after hearing three days of evidence into the circumstances surrounding 26-year-old Darren Tannahill's death.

His verdict "deeply disappointed'' Darren's family who said they felt "very angry" that Darren "had not received the level care" he should have. "We certainly don't have closure," said his sister, Teresa.

His mother, Joyce, said they had lost "a gentle giant" of a son who "was happy, helpful, thoughtful, and was always caring for others.'' It took nine years for the inquest to open due to a police investigation and other issues, although no charges were ever brought.

Darren, who lived with his parents in Fishguard, had been sectioned under the Mental Health Act because he had been behaving in a "bizarre'' way and doctors feared for his safety. He had not been taking the medication he was prescribed to control agoraphobia and schizophrenia.

At St David's Hospital he was sedated through a process known as rapid tranquillisation.

Although the coroner said he was satisfied the decision to section Darren was justified, as was the decision to authorise rapid tranquillisation, he believed the aftercare had been "less than satisfactory''.

There was no record that proper checks were kept of his blood pressure and pulse and at one point a nurse had monitored him from her office, despite a doctor recommending level one observation - watching from touching distance.

However, John Owen told the inquest: "It is not reasonable for me to come to a conclusion that there has been a connection between those deficiencies and the cause of death.'' Darren's family had questioned the resuscitation training given to staff and equipment available on the ward. But the coroner said the "absence of records" made it difficult for him to reach any conclusion on that front.

Mr Owen agreed with the Home Office pathologist that the cause of death had been "sudden and unexplained'' after the administration of an intramuscular injection of Droperidol and Lorazepam.

He said he was satisfied that on the "balance of probability'' Droperidol, which Darren had previously had an adverse reaction to and was later withdrawn from use, did not cause Darren's death.

Mr Owen said in certain circumstances a coroner will write to the Home Office after giving a verdict with recommendations for change.

But, Mr Owen said he would not do this because the Pembrokeshire and Derwen NHS Trust (now the Hywel Dda Trust) had addressed deficiencies identified following Darren's death.

Medical records can now be accessed electronically and resuscitation equipment is available on wards. The trust also implemented guidelines in 2005 for administering rapid tranquillisation which took account of the recommendations of the National Institute for Health and Clinical Excellence (NICE).

St David's Hospital has now closed and care provided at purpose-built facilities in Haverfordwest and Carmarthen.

The Hywel Dda NHS Trust, which offered its "sincerest sympathy'' to Darren's family, said since 1999 there had been significant developments around the approach to mental health care, such as assertive outreach, crisis resolution and home treatment teams. This had changed the way in which most patients experienced such care, said a trust spokesman.

"The coroner observed that, in light of the improvements already implemented, the issues identified from nine years ago appear to have been addressed by the trust,'' said the spokesman.

"We understand that this is a difficult time for Darren's family and sincerely hope that this will bring some comfort to them at this time."

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