'Mum was left like a rabid dog and then mocked before dying'

A mum was "left like a dog with rabies" in a mental health facility where she was mocked by staff, says her daughter, and aninquest found that neglect contributed to her painful and traumatic death.

Margaret Mary Picton, known as Rita, died of aspiration pneumonia after choking on paper in September, 2022. While Rita, from St Helens, Merseyside died nearly three years ago, her devastated family had to wait until earlier this year for an inquest that would shed light on the neglect she suffered on the Fern Ward at Leigh Moss Hospital inLiverpool, which is operated by the region's Mersey Care mental health trust and specifically cares for patients with dementia.

Rita was 76 when she died but her health had been declining for some years after she began suffering from vascular dementia. "Mum was a very straightforward person, she would always tell it like it is," explained Rita's daughter, Rachel Burkey, 51. "She was very good natured and would always give her kids whatever we needed. She was a really good mum.

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"But a few years ago I noticed changes in her behaviour and her mood. Then my sister called to say she was confused and had come at her with a knife. It was horrendous."

Having been in a care home in St Helens, Rita's unpredictable and at times aggressive behaviour saw her sectioned under the Mental Health Act and taken to Leigh Moss on September 10, reported theLiverpool Echo.

On admission to the ward, it was decided that Rita should be observed at least every 15 minutes because of her changing mood and previous incidents of self harming.

An inquest at Liverpool Coroner's Court in January heard that staff on the ward missed opportunities to respond to Rita's erratic and dangerous behaviour, including stabbing herself with a pen. Staff did not escalate the incidents and observations were not correctly carried out.

One staff member, who was responsible for engaging with Rita on the wards did not make any "meaningful attempts to engage positively" with her, the inquest concluded. Worse than that, he was described as "unprofessional and disrespectful" when making gestures towards her.

Rachel elaborated on the behaviour of this staff member having seen CCTV images during the inquest. She added: "On the CCTV I have seen, she is in the corner, she looks like she has been there for hours. To me, she looked like she had been left like a dog with rabies.

"He (the staff member) was pretending to shoot a bow and arrow at her and pretending to shoot himself in the head. He even mimicked her when she was eating paper."

The coroner Helen Rimmer concluded that observations of Rita were "limited and of poor quality", meaning further opportunities were missed to identify a deterioration in her behaviour and to escalate concerns. For one hour there were no observations of her at all due to a "communication breakdown" between staff.

The coroner stated: "This was fundamental basic care and supervision, which more likely than not would have led to an escalation and review of Rita’s behaviour and presentation at that time had the requisite observations been undertaken."

The inquest heard that CCTV footage then showed at least five, possibly six occasions where Rita could be seen placing paper in her mouth, with staff present on all occasions. While they did intervene and remove some paper from her, they again did not escalate concerns.

In the evening of September 10, one member of staff saw Rita eating paper and did not remove it from her, instead miming an action of eating paper to someone else. He then sat with his back to Rita, failing to properly supervise or monitor her.

In her record of inquest, the coroner states: "Staff were aware of the choking risk of paper eating but failed to escalate matters, intervene, and appropriately monitor Rita.

She added: "It is more likely than not that had staff been appropriately observing and supporting Rita, they would have removed all paper from her or in the alternative escalated concerns about Rita eating paper earlier with the nurse in charge who would then have removed any paper from Rita, identified any continuing concerns and reviewed risks, which would have included consideration of the level of Rita’s supportive observations. This would have more likely than not prevented Rita from eating paper and subsequently choking."

Soon after, Rita collapsed and shockingly the staff who had seen her eating paper did not tell those performing CPR on her about this, so choking prevention measures were not considered.

Paramedics were called but were delayed by being locked out of the hospital building. When they did arrive, CPR had been ongoing for 25 minutes and Rita had gone into cardiac arrest twice before the paramedics were told that Rita had been eating paper prior to her collapsing. This delayed the paramedics from removing the paper, which was causing a blockage in Rita’s airway.

The coroner stated: "This was basic care and treatment that should have been undertaken and raised sooner. Not to have provided this basic care and information to professionals treating Rita was a gross failure which more likely than not hastened Rita’s death."

Rachel described these failures as "sickening", adding: "I can't believe they didn't even tell the paramedics that she had chewed paper until the very end. She had two cardiac arrests before they said anything. It is hard to think of that being her end."

Rita was taken to the Royal Liverpool Hospital where she went onto develop aspiration pneumonia and died on September 26 2022.

The coroner stated: "The aspiration pneumonia was more likely than not caused by Rita eating the paper, the resuscitation efforts that followed Rita eating the paper and collapsing or a combination of both. The failure to immediately notify staff and paramedics that Rita had ingested paper prior to her collapse represented a failure to render care that would more likely than not have prolonged her life.

Ms Rimmer added: "Having identified a specific gross failure which clearly amounts to neglect, it is also found that the accumulation of the catalogue of missed opportunities throughout the care of Rita by those involved in her care at Leigh Moss Hospital, namely the acts and omissions mentioned above, have as a whole also amounted to neglect."

Knowing that there had been failures in her mum's care, Rachel and her sister Jak fought for justice but had to wait years for the inquest to take place because of various delays. They instructed a barrister for the hearing to ensure they got the right result for their mum.

"I thought, I am going to get my mum justice," added Rachel. "I am going to make them tell me what they did. This was about accountability.

"We came out of that inquest and we said 'we've done you proud mum', she was neglected and people will know that. I feel like we got justice and by sharing it with the ECHO everyone will know what happened."

Rachel added: "Mum was a fighter, even on that day on the CCTV she was still giving as good as she got. We will remember her fight and her spirit, she went through a lot and that's the sad thing. She shouldn't have been left like a dog in the corner, with no one doing anything except teasing her and basically watching her die.

But I think mum would be looking down now and saying 'good on you girls' for us fighting like this. I can see her saying that, she was really feisty. She was a lovely mum and a strong woman who wouldn't back down from what she thought was right."

In a statement, A Mersey Care NHS Foundation Trust spokesperson said, “We’d like to again offer our sincere condolences to the family, friends and loved ones of Margaret Mary Picton. While we are unable to comment on individual patient care because of rules governing patient confidentiality, we can confirm that we fully co-operated with the Coroner’s investigation. We also accept the findings of the Assistant Coroner, Helen Rimmer and would like to sincerely apologise for the shortcomings in care.

"A patient safety learning review was undertaken following the tragic circumstances which led to Mrs Picton’s death. This is in line with the Patient Safety Incident Response Framework (PSIRF) which is the NHS approach for responding to patient safety incidents, focussing on learning and making immediate changes to ensure patient safety, through a compassionate, system based and proportionate approach.

"As a Trust, we remain committed to learning with efforts to ensure that incidents of this nature do not recur.”