KGH failures left patient with dementia wandering the streets before he was hit in fatal crash

An elderly man with dementia who was killed by a careless driver as he crossed a road was wandering the streets after KGH s catastrophic failures.

Michael Reid, 75, had been taken to the Rothwell Road hospital at 7.30pm on September 8, 2019, in a confused state and with suspected sepsis.

But after he wasn't closely monitored because no mental capacity assessment was carried out, and with the majors department doors left wide open, he was able to walk out at 10.40pm without anyone noticing for over an hour - because staff wrongly assumed his bed was empty because he had been moved.

Three hours later and just over half-a-mile away he was mown down by Ross Eaton, who had never passed a driving test, near the double roundabout in Northampton Road. His family believe he was trying to walk back to Gabriel Court care home in Broadway, where he lived. The hospital has since apologised for its failures.

Mr Reid's furious daughter Misty told the Northants Telegraph: "The driver is not a very good man at all, but my dad should not have been out there in the first place.

"He should have been safe, in a hospital bed, on a ward, in a gown and being monitored."

Mr Reid was returned to the hospital after the crash before being taken to Coventry for injuries including a head injury, a broken pelvis and a broken ankle.

Later that week having been placed in intensive care his condition deteriorated and he died, leaving behind a devastated family.

But as Misty started to process what had happened, she started to get angry. She could not understand why her dad was out at 1.45am.

He, a serious incident report concluded, was out because he was not closely monitored at the hospital and staff wrongly believed his bed was empty because he had been moved to another ward.

The report found Mr Reid was taken to a bed in the majors area at about 8.30pm, assessed by an advanced clinical practitioner an hour later and a bed was then allocated for him in the medical assessment unit at about 10.35pm.

At that time, staff looking after him in the majors area moved some other patients to their allocated wards. The majors area was not secure, with doors left open for easy access and exit because call bells could not be heard when they were closed.

Mr Reid walked out at 10.41pm, CCTV later showed, and was not in a gown. Despite an ambulance crew documenting that he lacked capacity, he was not being closely observed. This was because there was no handover to nursing staff when he was transferred to the majors area, and a formal mental capacity assessment was not completed during any assessment of him.

Nine minutes later, at 10.50pm, the hospital tracker recognised his bed was empty and those in the majors area assumed this was because he had been moved to another ward. It was not until 11.45pm, when the staff looking after him who had taken patients to other wards at 10.35pm returned, that it was noted that he had absconded.

The report said the department was busy and overcrowded, which may have contributed to difficulties with communication between teams.

Hospital security staff searched for Mr Reid for just over 30 minutes but could not find him, and police were called at 12.17am. Hospital bosses said this followed the trust's missing person policy. But Misty said that her dad was not reported as a missing person with dementia. It's understood that had he been, a police helicopter would have taken to the skies to try and help find him. About 90 minutes after police were called Mr Reid was fatally hit.

Misty, who grew up in Thrapston with her dad and now lives in Cornwall, said: "They (the hospital) failed in their duty of care. Words cannot describe how angry I am with them.

"They need to understand that people like this need to be monitored because if they abscond it's dangerous.

"It could have been any driver that could have hit my dad that night."

As part of the serious incident review the hospital said they have since put in place new measures to prevent similar incidents from happening.

They include:

- Introducing new swipe card restrictions in their A&E majors unit so patients or relatives must ask for permission from staff before being able to be swiped out and leave the area

- Introducing a new call bell system so that when a patient alarm is sounded all staff can hear it

- Creating a new handover process for A&E patients which precisely identifies which individuals are responsible for patients, and which includes a system whereby a senior nurse must check out patients and ensure the details are entered onto their electronic patient tracking system, so that patients movements are closely monitored

- Ensuring that all A&E staff receive training in mental capacity assessments and understand its importance in care pathways

Kettering General Hospital’s chief operating officer, Fay Gordon, said: “We would like to offer our sincere apologies to Mr Reid’s family for their loss and for the aspects of Michael’s care, and supervision on September 8, 2019, that fell short of what we would aim to achieve for our patients.

“We have carried out a very detailed investigation into the circumstances that led to Michael being able to leave the hospital and have identified ways that we can reduce the risk of this kind of incident occurring again."

She added: “We have shared the findings of our report with Mr Reid’s family and are happy to meet with them if they have any questions they would like to ask.”

Misty, who said the family had been denied a coroner's inquest, said nothing could bring her dad back and hoped the hospital's response was "not just lip service".

She said: "They should have had all of these policies in place beforehand. It's just basic safeguarding."

Misty has also since complained to Gabriel Court care home after nobody accompanied her dad to hospital, alleging a failure in their duty of care.

A letter sent by home managing director Jasbinder Garcha said they didn't because Mr Reid had 'capacity' when paramedics arrived to assess him.

It said: "The home's policy states that where a resident has capacity, it is not necessary for a staff member to accompany the individual to the hospital."

The home, which was rated as requires improvement by the Care Quality Commission last year, did not respond to a request for comment.

Misty, 35, said: "Had someone gone with him from Gabriel Court this would not have happened."

In his earlier life Mr Reid had joined the Army as an engineer before taking a job at a computer firm, later spending about 15 years working in a prison as a computer teacher.

He travelled the world and got his driving licence by driving a lorry in the desert in Yemen.

Misty said: "He had a really good sense of humour and sense of fun."

The fatal crash left Mr Reid's killer Ross Eaton, of Union Street in Kettering, staring at the walls of a prison cell.

He was jailed for a total of 34 months last week after admitting causing death by careless driving.

Northampton Crown Court heard the 47-year-old had no licence, no insurance and had taken his brother's Saab when he failed to spot Mr Reid in the well-lit road and drove into him. He initially left the scene before returning.

He later implied Mr Reid was 'almost to blame' for the incident. Just ten days after the crash he was caught behind the wheel again.

Lead investigator, Detective Constable Mark Griffin, said: “Ross Eaton has shown a complete lack of regard for the devastation he has caused the family of Michael Reid who will have to live forever without him because of Eaton’s thoughtless and stupid actions."