Open verdict over hospital death


Darren Tannahill was described by his family as a "gentle giant"



There were "serious deficiencies" in care given to a man who died hours after entering hospital but they did not amount to neglect, a coroner said.
Darren Tannahill, 26, of Fishguard, was admitted to St David's Hospital in Carmarthen suffering from schizophrenia in 1999 where he was sedated.
But following the injections he was not properly monitored, an inquest heard.
His family said they were "deeply disappointed" with the open verdict recorded by coroner John Owen.
A three day hearing was held in Llanelli last month and Mr Owen returned to outline his findings on Thursday.
It had taken nine years for the inquest to open due to a police investigation and other issues although no charges were ever brought.
Mr Tannahill, a monumental stonemason, was suffering from psychosis in the months before his death.
Late on the evening of 11 May he went missing from his parents house and when he returned the following day locked himself in a bathroom.
Doctors were called and sectioned him under the mental health act.
Upon being admitted to hospital he was given a dosage of Droperidol and Lorazepam.

We certainly don't have closure


Teresa Tannahill


A nurse stayed at his bedside for the first hour but after that he was monitored by a colleague from a nearby office, the inquest was told.
At about 2315 BST it was noticed that saliva was coming from his mouth. When his pulse was checked it was found to be faint and his lips started turning blue.
Despite efforts to revive him he was certified dead at 2355 BST.
Experts had told the coroner that Mr Tannahill's temperature, respiration and blood pressure should have been closely monitored and records kept.
The coroner concluded there were "very serious deficiencies in the care of Mr Tannahill."
Mr Tannahill's family had also 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.
Recording his verdict he said he had been assured by the Hywel Dda NHS Trust - the successor to the Pembrokeshire and Derwen NHS Trust - that "the deficiencies had been addressed".
Speaking after the verdict Mr Tannahill's mother Joyce said they had lost "a gentle giant" of a son who "was happy, helpful, thoughtful and was always caring for others.
His sister Teresa said they were "deeply disappointed" with the open verdict and felt "very angry" her brother "had not received the level care" he should have.
"We certainly don't have closure," she added.
The trust offered its "sincerest sympathy" to the family.
A spokesperson said: "It is important to recognise that this happened nine years ago.
"Since then, there have been a number of nationally implemented changes to published guidance, practice, training and use of drugs. "These have been implemented within our trust, as well as trusts nationally, and include improvements in the use of rapid tranquilisation, resuscitation, training and observation, the national withdrawal of the drug in use at that time and the introduction of electronic records systems. "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."