NHSE warned of ‘inaccurate’ and ‘unethical’ investigation into man’s death

An independent investigation into the death of a man with autism and learning difficulties in NHS care may never be published in full as his sister has rejected several drafts as inaccurate, telling NHS England they were ‘totally unethical’.

Anthony Dawson died from a burst gastric ulcer in Ashmount, a residential care home run by Surrey and Borders Partnership Foundation Trust, in May 2015. The jury at an inquest into his death found there were gross failings in his care and his death was contributed to by neglect.

NHS England commissioned an independent investigation into the incident from Sancus Solutions in June 2017. But seven years after Mr Dawson’s death the investigation’s report has yet to be published, despite several reports being submitted.

His sister, Julia Dawson, has written to NHS chief executive Amanda Pritchard in recent weeks saying: “The investigation has not had my brother at its heart which we were assured would be the case” and that its reports had been “totally unethical”.

Ms Dawson has asked that only the executive summary of the latest draft of the investigation be published, alongside a statement saying that she feels it has inaccuracies and misses out important points.

She says that successive drafts have misrepresented her brother’s situation and failed to address what she believes was the real cause of his death – the frequent use of NSAIDs (ibuprofen) without any measures taken to protect his stomach. This ultimately led to the undiagnosed gastric ulcer bursting. An expert witness told the inquest into his death that treatment with proton pump inhibitors and stopping NSAIDs would have eradicated the ulcer.

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Source: HSJ, 4 April 2022