DR Fox Report

CONFIDENTIAL
MEDICO-LEGAL
PSYCHIATRIC REPORT
(heavily edited for mum's blog but important for the public to understand what
drives our action - to save mum's life)

Name: Mrs Vera Waylor
Address: Bowles Lodge
All Saints Road
Hawkhurst
Cranbrook
TN18 4HT
Date of Birth: 22 October 1921

Report prepared by: Dr G C Fox
Consultant Psychiatrist/Clinical Senior Lecturer
Norwich Medical School
University of East Anglia
Norfolk
NR4 7TJ

Tel: 01603 593583
Fax: 01424 714584

Report requested by: Hossacks Solicitors
89 Broadway
Kettering
Northamptonshire
NN15 6DF

Date of report: 10
th
June 2011
2
Report by: Dr Chris Fox
On: Vera Waylor
_________________________________________________________________________

CONTENTS
Paragraph number Paragraph contents Page number

1. Introduction 3
3
On: Vera Waylor
_________________________________________________________________________

1. Introduction

1.1 The Writer
1.1.1 I am Dr George Christopher Fox. I am accredited with the General Medical
Council as a Consultant of Old Age and Adult Psychiatry, registration number

2. The issues addressed 3

3. My investigation of the facts 5

4. Opinion 15

5. Statement of compliance 20

6. Statement of truth 20

4
On: Vera Waylor
_________________________________________________________________________

3543315. I graduated with a Bachelor of Science in Biochemistry from the
University of London in 1988. I qualified as a Doctor in 1991. I passed my
membership to The Royal College of Psychiatrists in 1997. I was awarded a
Master of Medical Sciences and Behavioural and Psychological Sciences in 1999
from the University of Leeds. I was awarded my MD in 2011 on anger and
aggression in older people. I was accredited as specialist in 2001. I have worked
in the NHS as a Consultant since then in Old Age Psychiatry in Kent and since
August 2010 in Norfolk. I am active in research in psychiatry and am involved in
international collaborative research looking at care and the impact of care
environments. I am a training supervisor of Junior Doctors. I regularly undertake
clinical assessment of older patients with mental health difficulties in the
community.

2. The issues addressed

2.1 In a letter of instruction dated 5 April 2011 from Hossacks Solicitors I was
requested to meet with Mrs Vera Waylor at her care home and address certain
specific issues.

2.2 I was informed that she was 89 years of age currently resident at Bowles Lodge
Home in Kent. It was described that she is registered blind due to macular
degeneration and was deaf in both ears and has difficulty with her hearing aid.
She also had osteoporosis and little muscle strength and a lack of feeling in her
fingertips as well as mild incontinence. She suffers from significant short term
memory loss and has been treated for depression in the 1970s. She had ECT for
one of these depressions. Her son stated that Vera had suffered memory loss in
her fifties and it was put down to ECT. Vera moved to Bowles Lodge on 29
November 2009 after a series of hospital admissions. In November 2010 it was
suspected that she had heart failure. I was informed that Vera is happy and
settled at Bowles Lodge and does not want to move. Her solicitor informed me
that she felt that Vera was orientated in person, place and date to give views but
did not have sufficient short term memory to retain information and the solicitor
did not feel that she had mental capacity for the proposed court proceedings.

5
On: Vera Waylor
_________________________________________________________________________

2.32.2 I was informed Kent County Council on 13 January 2011 had decided to close
and demolish Bowles Lodge Care Home and residents were informed on the 14
th

January 2011. In the background I was informed that a previous case with the
closure of Northam House in Kettering resulted in 15 out of 41 residents dying 12
months post closure and the mortality rate doubled compared to the control
group of 24 elderly peoples homes owned by the same local authority. In recent
cases in Hull, Southampton and Wolverhampton the outcome of mortality
statistics were obtained from clients relatives and this indicated 25 deaths out of
54 people occurring after news of closure, adverse decisions by the courts and
the moves themselves. It described that in a recent case of Watts, the judgment
was that if there was firm evidence that Mrs Watts would shorten her life a
decision of the court would have been quite different. I was informed that each
case will rely on its own facts and information put before a judge. Mortality
prediction cannot be an exact science but I was further informed that outcomes
showed that Professor Katonas predictions of early mortality were 100 per cent
correct for the individuals he reported on. His only incorrect prediction was that a
person was at low risk who died within months of moving. I was informed that in
the Watts case, despite the councils approach goals being implemented carefully
and conscientiously and adhered to, there were multiple deaths.

2.42.3 I was requested in my assessment of Mrs Waylor to consider the following:
(1) Bearing in mind the council has given the reasons for closure, do these
amount to an acceptable clinical risk for the involuntary transfer of Vera
Waylor?;
(2) What would Veras life expectancy be if she were not moved?;
(3) What, if any, effects on life expectancy would there be if Vera were subject
to an involuntary transfer?;
(4) What is the general extent of risk of death for people at Bowles Lodge? (I
was going to be provided with the actual mortality statistics to consider this).
(5) Can the reasons for premature mortality in cases of involuntary transfer of
the elderly be found solely in badly managed transfers?
(6) Bearing in mind that the council refused to assess the risk to Vera prior to a
decision being made do you consider the following statement be sufficiently
detailed for decision making lay people to comprehend the clinical effects of
involuntary transfer? "With regard to your point that members will not be
6
On: Vera Waylor
_________________________________________________________________________

able to make a decision about the closure unless they understand the impact
on the individuals, Members will be made aware that Kent Adult Social
Services (KASS) has considerable experiences in moving older people both in
a structured planned way and as a result of an emergency. Members will
expect and good practice dictates that should the proposals be agreed, every
resident will receive an up to date assessment that looks at their current
needs together with their preferences and those of their families with regard
to the nature and location of alternative provision. KASS will use its
extensive experience in the assessments to establish a solid framework for
each individual transition and that a plan will be implemented carefully and
at a pace that suits the individual. As you may know, older people sometimes
have to move from our homes; for instance if peoples needs change and
they require nursing care. Between January 2008 and July 2010, ten
residents moved from Bowles Lodge to alternate homes better placed to
meet their needs
(7) Is there a medical package and if so, would that reduce the level of risk to
make it clinically acceptable for Vera to move?;
(8) Where do Veras best interests lie?

3. My investigation of the facts

3.1 Medical records
3.1.1 Mention of overdose deliberate self harm attempt December 1966, recurrent
depressive disorder noted 1974 with various admissions ECT.
3.1.1 Osteopenia on 17 October 2005.
3.1.1 abdominal aneurysm 26 June 2006, patient declined operation dated 30 May
2009.
3.1.1 1 August 2006 anxiety with depression.
3.1.1 Surgical abdominal procedures for hernia repair and obstruction in 2008.
3.1.1 Mild memory disturbance 22 January 2009.
3.1.1 Chronic kidney disease stage three 22 January 2009.
7
On: Vera Waylor
_________________________________________________________________________

3.1.1 Closed fracture left wrist October 2009.
3.1.1 Chest infection October 2009.
3.1.1 Suspected congestive cardiac failure 8 October 2009.
3.1.1 Heart echo cardiogram showed impaired left ventricular function severe
aortic stenosis.
3.1.1 8 October 2009, trivial aortic regurgitation, mild tricuspid regurgitation.
3.1.1 July 2010 diagnosed with confusion.

3.1.2 A letter dated 22 November 1966 reported that she was reviewed in gynaecology
and told the gynaecologist that she had shakiness and incompetence feelings and
she was started by the GP on lithium, an anxiolytic but she did not feel any
better and she was requested to go and see her GP.

3.1.3 A letter from Dr Corney, Medical Registrar, dated 22 December 1966 reported that
post her D & C procedure she felt weak, depressed, nervous and irritable and had
palpitations, she had lost a lot of weight. The physician thought that she could
have an anxiety problem and arranged further tests but suggested she continue
with sedation.

3.1.4 A letter from Dr Woods, Consultant Physician, dated 7 January 1967 to GP reported
that the physician was of the view that symptoms are related to her nerves and
were not physical in origin.

3.1.5 Discharge from hospital, dated 30 December 1966 to 31 January 1967 reported she
was admitted after an overdose. She was agitated and disturbed. She was
unaware of the real cause of her troubles and was not able to do work properly.
Just before Christmas she wanted to kill herself and she took a bottle of
phenobarbitone but could not take them and handed them to her husband. She
mentioned she had divorced her first husband and this was the second marriage.
She had two children from the first marriage. She described that she gets on well
with her present husband and he has a good job and earns a high salary and she
8
On: Vera Waylor
_________________________________________________________________________

does not need to work. She was worried about her appearance. Mentally she was
agitated and disturbed. She was given sedation and antidepressants and
uneventful recovery and diagnosis was depression.

3.1.6 Discharge summary from psychiatry, dated 26 March 1964 to 18 May 1974. This was
for depression. It described that she had previously had a short spell in another
psychiatric hospital for depression. Since the death of her husband she had been
feeling depressed and this was becoming worse. It described she was very
agitated and depressed and felt guilty and suicidal. She felt that the death of her
husband contributed to her depression. She had had four treatments of ECT and
was given antidepressant medication and made a good recovery.

3.1.7 Handwritten entries report anxiety in 1976.

3.1.8 A letter from psychiatric services, dated 11 January 1977 reported that the patient
had been admitted to hospital suffering from recurrent depression since
December 1976 and she had further five ECT and medication. She made good
progress and was discharged by 31 December 1976.

3.1.9 Handwritten entry dated 19 February 1997 reported anxiety state.

3.1.10On 14 January 2000 the patient had some anxiety with depression, move to live with
son now off.

3.1.11On 4 February 2000 patient now back to normal.

3.1.12On 12 November 2000 had a chat to patient, very worried, sleep problems.

3.1.13On 24 November 2000 patient was saying very anxious.

3.1.14On 2 October 2001 feeling low again, not sleeping.
9
On: Vera Waylor
_________________________________________________________________________

3.1.15On 29 November 2002 had a chat to patient, antidepressants adjusted, given
sertraline.

3.1.16 Further entry for depression in 2003.

3.1.17 Entry May 2005 - known osteoporosis.

3.1.18Entry 1 August 2005 anxiety state with depression. She described she was living
with her son and she was starting antidepressant medication. On 1 August 2005
mentioned that she had curvature of the spine and marked scoliosis since some
time ago, refer for further investigations.

3.1.19Entry 29 September 2005 reported senile macular degeneration bilateral, registered
partially sighted, referred to ophthalmology.

3.1.20Entry 17 October 2005 reported that an X-ray showed that she had lost vertebral
height, no fractures and she was given medication to manage this.

3.1.21Entry 17 December 2005 mentions that she had senile macular degeneration but she
declined cataract surgery. Mention that she had a femoral hernia operation in
November 2005.

3.1.22Entry 1 August 2006 mentions anxiety with depression, had been on trazadone
antidepressant for 18 months, found it helpful for depression and sleeping but
wanted to continue, she was told she would need medication for life.

3.1.23Entry 26 June 2007 - Aortic aneurysm, discussed with patients son, she would
rather die than have an operation.

3.1.24Entry 26 March 2007 - chronic kidney disease stage three.
10
On: Vera Waylor
_________________________________________________________________________

3.1.25Entry 23 January 2008 - recurrent fall, described she had three now, son asked for
an assessment, been referred to the falls team. Queried whether her
antidepressants should be changed as that can be aggravating her falls.

3.1.26Entry January 2008 for recurrent fall, community team going to review.

3.1.27Entry 2009 - described from son, had moved to a flat, not liking it but could not face
another move, has carer three times a day and attends a day centre. Agreed
memory was poor but stated this part of old age. Patient is accepting reduced
mobility, sight, hearing and loneliness, patient going to be deregistered due to
distance from surgery.

3.1.28Entry 27 January 2009 - mention of mild memory disturbance.

3.1.29Entry 3 June 2010 recorded leg ulcers and on antibiotics for these.

3.1.30Entry 8 July 2010 - suspected urinary tract infection, had two falls yesterday,
banged her head, probably tripped, talk a bit confused. Walking with Zimmer
frame. Not able to assess and mental state distress. Given antibiotic, lips dry
fluids encouraged.

3.1.31Entry 15 July 2010 - confusion, had another fall, more confused than usual,
complaining of pain where she banged her head, mobilised with Zimmer frame,
has been given urine test, falls team referral and CT scan, staff keep an eye.

3.1.32Entry 16 September 2010 - suspected urinary tract infection, stress incontinence.
Antibiotics. Possibly going to add on an antidepressant if needed.

3.1.33Entry 23 September 2010 - acute conjunctivitis, given treatment for this.
11
On: Vera Waylor
_________________________________________________________________________

3.2 Medical correspondence

3.2.1 Letter from Mr Bentley, Surgeon to Mr Porter, dated 13 February 2008

3.2.1.1 This described that Mrs Waylor was admitted into Emergency on 2 January 2008
with signs of bowel obstruction. She had a relapsed hernia which was irreducible.
She was treated and had a CT scan which showed obstruction to her bowels. An
emergency operation was required-operation no acute strangulation of the hernia
but there was a mass near the intestine causing an obstruction and a bit of the
bowel had become stuck in her hernia. These had become stuck together and this
was causing the obstruction. The surgeon explained he had to remove some of
her intestine to reduce the obstruction. He was going to have carry out a repair.
It was felt that it would be unlikely she would develop future hernias. It was
described that other patients who have had major abdominal surgery there was a
30 per cent chance that they would have further trouble.

3.2.2 Letter from Dr Pattenehetti, Staff Grade Physician, dated 10 September 2010

3.2.2.1 This described that Mrs Waylor had three falls over the last six weeks. She
remembered only one fall although she was not sure why it happened. She was
trying to get up from a chair and just fell. She did not lose consciousness or have
any giddiness, dizziness or palpitations but she felt that she had no warning and
might fall again.
3.2.2.2 It was described that none of the falls were witnessed by carers. She had been
noticeably more confused and forgetful and she agreed she had become more
forgetful but this was usually for day to day things not for past memory. She had
been treated for a urinary tract infection. She had a past medical history of
macular degeneration, impaired hearing, osteoporosis, severe aortic stenosis with
severely impaired ventricular function, globally dilated left ventricle with mild
tricuspid regurgitation and an echocardiogram from October 2009, a left wrist
fracture from October 2009, acute small bowel obstruction from January 2008.
She lived in a residential home and needed help with activities of daily living but
can feed herself, walk independently. It was recommended from this assessment
that it was felt that the fall related to cardiac symptoms and her antidepressants
12
On: Vera Waylor
_________________________________________________________________________

were suggested to be reduced or perhaps changed to another one. She was going
to have further investigations of her heart.

3.2.3 Letter from Dr Preston, Register Physician, dated 25 January 2011

3.2.3.1 This described that she was reviewed with dependent for most of her activities of
daily living but can walk with a Zimmer frame. She had a cardiogram in
November 2007 which said severe aortic stenosis and severely impaired left
ventricular function. She had a 24 hour ECG which showed frequent ectopics and
short run of abnormalities and supraventricular ectopics. It was described she
had only had one fall since last being seen when she slipped. It was described
that since reducing her trazadone it was felt by the physician that this had helped
her and she was going to be reviewed again.

3.3 Individual Needs Portrayal, dated 2 December 2009

3.3.1 This described Mrs Waylor realised that she could not cope alone at home and
was looking for residential care. She mentioned that she had had three
admissions recently. She had four calls a day from Social Services while living at
home and two day centre attendances at Woodgate and one at Townlock. It
described her son had provided with support such as shopping, laundry,
medication and paperwork. It described with cognition she was able to make
simple decisions but her son would advocate. She can understand and assimilate
information but her short term memory is poor and she will forget some
information. There is mention that she was happy with the current situation but
can become frustrated and upset at her inability to do things for herself and felt
useless.

3.3.2 She stated that she liked to be with other people but in the past she had declined
social invites and she may not interact directly but feels happier with people
around for security.

3.3.3 It described she is deaf in both ears and this could hamper communication but
she could express her needs and wishes. There was mention that she had had
lots of falls and also had a fall at Bowles Lodge. She had needed supervision to
13
On: Vera Waylor
_________________________________________________________________________

keep her safe and was infirm. It described her weight was stable and she had a
good appetite. She was continent of urine but needed help at night and there
was a risk of incontinence. It mentioned that she slept well but gets up to go to
the loo and there is a risk of falls during that time.

3.3.4 There was mention that she had an enduring power of attorney with her son. She
enjoys television. She used to enjoy reading but she could not get on with
reading books so she could not use the controls but liked to socialise. She has
generally been deteriorating and getting frailer with increasing falls and did not
feel able to cope alone any longer. She had had periods of rehabilitation in the
past.

3.3.5 It was described that she was able to wash her hands and face but needed
assistance with other aspects of washing and dressing. She used to go to church
but now was unable. It described she needed the following: (1) assistance
washing and dressing; (2) Mobility there was a risk of falls and further injury; (3)
Meals - she was unable to prepare meals or snacks; (4) She needed night time
assistance getting to the lavatory safely; (5) Medication needs to be given; and
(6) General supervision to keep safe.

3.4 Residential Review, dated 28 January 2010

3.4.1 This reported that Mrs Waylor enjoyed her period of respite at Bowles Lodge and
expressed a wish to remain at Bowles Lodge on a permanent basis. She settled
well. She was a bit forgetful and needed some help with personal care and was
quite an anxious lady who will go to the toilet frequently and at times requires
help from the carer. She enjoys her meals and has maintained her body weight.
She likes to watch television and prefers to watch social activities than
participate. She required support when going to appointments and her son was
going to continue to support her.

3.5 Residential Review, dated 26 November 2010

3.5.1 This described that Mrs Waylor was well at the time of her review and alert but
continues to be forgetful. It mentioned she had osteoporosis and curvature of her
14
On: Vera Waylor
_________________________________________________________________________

spine. She mobilises with a Zimmer frame and is falling less frequently. Her son
believed the antidepressants may have affected her mobility and she was no
longer on that. She was seeing her GP and a heart investigation. Her GP
suspected that she may have heart failure. It described that there had been
improvements with her hearing. She continued to sleep well. She is washing her
hands and face independently but prefers to have wash rather than a bath. She
sees the hairdresser regularly and the chiropodist and takes pride in her
appearance. She maintained good food and fluid intake but she does not always
remember. She does participate in social activities and enjoys them. It described
that when asked about Christmas she said she was worried as she did not know
where she would be but she was reassured that she would definitely be spending
time at Bowles Lodge. Her son explained that she had been missing other
residents and was very anxious about the future and what will happen to her.

3.6 Interview with Vera Waylor

3.6.1 I met Mrs Waylor with her son Mr Porter on the 6
th
April 2011 at the
Bowles Lodge Care Home. She told me that she knew she was aged 89 and
mentioned she was a retired secretary. She told me that she was unaware of
where she was living initially. Her son told me that it took her six months to
settle in at Bowles Lodge and that she had lived there since 29 November 2009.
Before then she had lived in a flat locally.
3.6.2 She did have a couple of hospital admissions and she had fallen and had a
fracture. She went on an enhanced care package and a placement was
recommended her son told me. She eventually ended up in a permanent
placement at Bowles Lodge after being transferred from respite.

3.6.3 From my observations and discussions with staff and Mrs Waylors son, I was
informed that Bowles Lodge is a residential facility. I was also informed that her
General Practitioner was responsible for her physical care in the care home.

3.6.4 Her son described that she has deteriorated since she has been in the care home
and that she had lived alone until 2005 and then moved in with her son until
2008 and then lived with support for a year.

3.6.5 Her son described her as quite isolated before she came to Bowles Lodge.
694.;;1!ndent: Left: 0.76", No bullets or
numbering, Tab stops: Not at 0.76"
15
On: Vera Waylor
_________________________________________________________________________

3.6.6 Personal history

3.6.6.1 In her personal history she was somewhat vague about her own life details. She
told me she had one adopted brother. She was aware she had left school at 16.
During my assessment she became somewhat anxious asking why I was asking
these questions.
3.6.6.2 She did become distressed at times and asked to go to the toilet. Talking to her
son this is a common response when she feels distressed. She was aware she
was married in the 1950s for her first marriage but she was vague about the
number of marriages she has had and repeated that she could not remember
when I asked about her background.

3.6.7 Past medical history

3.6.7.1 She could not remember.

3.6.8 Past psychiatric history

3.6.8.1 She mentioned she had suffered with depression and she could not remember
the details of treatment that she had had in the past.

3.6.9 Premorbid personality

3.6.9.1 She said she was somewhat anxious. She described hobbies but she said she was
unable to do much. She can do some things. She said she can sit and read
possibly.
3.6.9.2 She told me she was an ex-heavy smoker. She denied any alcohol use.
3.6.9.3 She was Church of England by religion. She was uncertain what medication she
was taking and denied any allergies. Her son mentioned that she had her
antidepressants stopped recently because they had caused her to fall a lot.

3.6.10Current activities of daily living

16
On: Vera Waylor
_________________________________________________________________________

3.6.10.1 This was in discussion with her son and care staff at Bowles Lodge. It was
described that she can go to the toilet but she needs supervision. She feeds
herself and she can recognise her son. The staff reported no behavioural
difficulties, no behavioural challenge and no irritation. They mentioned last year
that she had punched another resident. She does get frustrated due to her
memory problems. At night time she is anxious. She does need supervision with
washing and dressing.

3.6.11Specific psychological issues

3.6.11.1 She told me that she can get a bit sad due to her frustration but her son felt it
was due to her frailty. She reported her sleep as fine and the carers confirmed
this was correct. Her appetite was reasonable.
3.6.11.2 She told me that she cannot really enjoy things and did not elaborate even with
suggestion I managed to get her to admit that she liked television.
3.6.11.3 She did admit again that she gets irritable due to her memory loss. She denied
any suicidal ideation and intent but she did appear anxious. I received a copy of
an email dated 8
th
June 2011 to Mr Porter from the manager of Bowles Lodge
which reported "displaying quite high anxiety levels, which have been increasing
since the weekend. She does not appear to be eating very well and today she
became distressed on mobilising which resulted in her requiring a wheelchair. The
team leader has had a discussion with your mum to see if anything is worrying
her especially and she stated that there is nothing in particular, and has said
again that she just wants to die.
3.6.11.4 There was no evidence of psychosis.

3.7 Mental state examination

3.7.1 She was casually dressed. She showed good eye contact. She was a little bit
restless and every so often asked to go to the toilet and wandered off and did not
come back. On at least two occasions we had to encourage her to come back into
the room.
3.7.2 I asked her about what she was aware was going on and she said that she was
happy where she was living and eventually told me she was aware she was living
in Bowles Lodge and wanted to remain there.
17
On: Vera Waylor
_________________________________________________________________________

3.7.3 During my assessment I attempted to persuade her that there are other options
and she appeared unable to accept this and became anxious when I suggested
she might have to go a new environment.
3.7.4 Her mood I would rate as quite anxious but not depressed. There was no
evidence of suicidal ideation or intent and no evidence of any psychosis.

3.7.5 Cognitively, I attempted two assessments. On the Addenbrookes cognitive
examination of she scored 9 which is severe. On the MMSE she scored 9 which
again can be rated as severe.

3.7.6 Regarding her insight, Mrs Waylor appeared to have some awareness as to where
she was living and when asked whether she wanted to stay where she was living
or move she was clear that she did not want to leave where she was living at
present. Attempts to persuade her otherwise were not successful and she
became anxious and distressed and left the room.

4. Opinion

4.1 Mrs Vera Waylor is an 89 year old resident of Bowles Lodge Nursing Home. She
has a significant medical history including cardiovascular impairment, history of
frequent falls, risk of fracture through osteoporosis and indeed previous fractures
as well as a significant past history of depression and anxiety.

4.2 What is clear and apparent from my assessment is that Mrs Waylor has a
dementing illness and it is a surprise that this has not been mentioned in the
medical records anywhere or in the social care records that have been provided.

4.3 Her scores are on the moderate to severe range for impairment and MMSE in
particularly was difficult to assess due to her vision impairment but at best I
would suggest even if she could see to fulfil the visual testing she would perhaps
score 14 or 15 on the MMSE which would again put her in the moderate rather
than severe spectrum of dementia.

4.4 In view of her cardiovascular history with her impaired heart function I would
suggest that it is probable that she has suffered some vascular dementia.
18
On: Vera Waylor
_________________________________________________________________________

4.54.1 (1) Bearing in mind the council has given the reasons for closure, do these
amount to an acceptable clinical risk for the involuntary transfer of Vera Waylor?

4.1.1 From reviewing Mrs Waylors history, she appears vulnerable to change. Certainly
when I assessed her she was somewhat anxious and she has a significant history
of depression and anxiety going back many years. Mrs Waylor is functioning in
her current placement and it will inevitably be difficult for her to change
environments with new staff, new environment and new co-residents. She does
have some awareness of her surroundings and indeed this is noted in some of
the care records. I would be very concerned about the impact of change would
have on her physical and mental health.
4.5.1
4.1.2 It is difficult for her as she is sensitive to the effect of medication so much so
that in the past her antidepressants were stopped due to the assumption that
this had aggravated her falls. If it became necessary as a result of transfer for
her care to be treated with antidepressants then this would possibly impair her
physical health due to her cardiac difficulties as well as have an impact on the
likelihood of falls and fracture risk which would inevitably shorten her lifespan.
4.5.2
4.1.3 In addition the elevation of stress could affect her heart and this could lead to
catastrophic decline potentially.
4.5.3
4.5.4 When I assessed her I was a stranger and asked her some probing questions,
she did become markedly anxious. I think the effect of a change of environment
would be similar on her mental state.
4.5.54.1.4It is my opinion that these risks would be clinically difficult to justify.

4.64.2(2) What would Veras life expectancy be if she were not moved?

4.6.14.2.1I would estimate from my clinical experience and from the literature that
Mrs Waylor perhaps has a minimum of three years duration of life in her
current placement if she were not to be moved.

694.;;1Font: Bold
19
On: Vera Waylor
_________________________________________________________________________

4.74.3 (3) What, if any, effects on life expectancy would there be if Vera were subject to
an involuntary transfer?

4.7.14.3.1I think this would have a dramatic effect on her lifespan. She is clearly
anxious already and changes such as moving would cause her to stress
and would potentially cause her depression to relapse and also put a
strain on her physical health with her impaired cardiac function, which
could tip her into either falling or having a cardiac event. In addition, the
depression would possibly aggravate her physical health and also
require treatment, which would have side effects which could again
aggravate her physical health and cause cardiac decompensation or a
fall. On the balance of probabilities, it is my opinion that her lifespan will
be shortened to 6-12 months from date of transfer if she were to be
transferred involuntarily, whatever mitigating measures were taken,
given her physical and psychological vulnerabilities.

4.4 (4) What is the general extent of risk of death for people at Bowles Lodge?
4.8
4.8.14.4.1There appears from Freedom of information enquiries to have been 6 mortalities
among residents in the 6 month period June-December 2010 as compared with
only 2 in the preceeding 6 months. The total number of deaths in 2009 were 3
by comparison. Without detailed information as to the case histories of the
individuals concerned it is unclear the aetiology of this increase is unclear.

4.94.5 (5) Can the reasons for premature mortality in cases of involuntary transfer of
the elderly be found solely in badly managed transfers?

4.9.14.5.1No. It is clear that even with the most well designed plan for transfer
taking plenty of time and orientation visits to new facilities, the distress
can be still insurmountable in some patients' cases and no amount of
properly managed transfer can necessarily overcome this impact on
residents. Those residents at particular risk would have significant co-
morbidity and cognitive impairment.

694.;;1Font: Bold
694.;;1Font color: Auto
694.;;1Font: Bold
20
On: Vera Waylor
_________________________________________________________________________

4.6 (6) Bearing in mind that the council refused to assess the risk to Vera prior to a
decision being made do you consider the following statement be sufficiently
detailed for decision making lay people to comprehend the clinical effects of
involuntary transfer? "With regard to your point that members will not be able to
make a decision about the closure unless they understand the impact on the
individuals, Members will be made aware that Kent Adult Social Services (KASS)
has considerable experiences in moving older people both in a structured planned
way and as a result of an emergency. Members will expect and good practice
dictates that should the proposals be agreed, every resident will receive an up to
date assessment that looks at their current needs together with their preferences
and those of their families with regard to the nature and location of alternative
provision. KASS will use its extensive experience in the assessments to establish
a solid framework for each individual transition and that a plan will be
implemented carefully and at a pace that suits the individual. As you may know,
older people sometimes have to move from our homes; for instance if peoples
needs change and they require nursing care. Between January 2008 and July
2010, ten residents moved from Bowles Lodge to alternate homes better placed
to meet their needs.
4.10
4.6.1 There appears to be no information provided to inform lay people to
enable them to comprehend the clinical effects of involuntary transfer
and assist in the decision making process. I would have expected some
information on potential health risks of transfer including risk of
premature mortality. This would allow informed decision making for
families and residents.
4.10.1
4.6.2 I am also unclear what "a pace that suits the individual means if they do not
want to move as this could be indeterminate. In addition, what is the evidence
that, in respect of the ten residents moved to alternate homes, these were
better placed to meet their needs?
4.10.2
4.114.7 (7) Is there a medical package and if so, would that reduce the level of risk to
make it clinically acceptable for Vera to move?

694.;;1Font: Bold
21
On: Vera Waylor
_________________________________________________________________________

4.7.1 I can really mainly comment from a psychiatric perspective and, if she were
involuntarily transferred, a close eye would need to be kept on her mood and
anxiety levels. It may well be that she would require a psychiatric medication
which would have to be very carefully considered due to the risk of adverse
effects of such medication.
4.11.1
4.7.2 From a general physical health perspective her General Practitioner may be able
to shed more light on this but clearly stress can aggravate the strain on the
cardiovascular system and with Mrs Waylor having a documented impaired
cardiovascular system, albeit controlled, this could cause her to decompensate
due to the impact of stress.
4.11.2
4.11.34.7.3 I was concerned to receive a copy of an email from the manager dated 8
th

June 2011 to Mr Porter from the manager of Bowles Lodge which reported
"displaying quite high anxiety levels, which have been increasing since the
weekend. She does not appear to be eating very well and today she became
distressed on mobilising which resulted in her requiring a wheelchair. The team
leader has had a discussion with your mum to see if anything is worrying her
especially and she stated that there is nothing in particular, and has said again
that she just wants to die.This supports my view of the delicate balance of Mrs
Waylors mental and physical health.

4.124.8 (8) Where do Veras best interests lie?

4.8.1 It is my considered opinion that Mrs Waylor requires support. It appears
that Bowles Lodge can meet her needs adequately. She is not profoundly
dependent and does not fulfil the criteria for continuing care in the
documents I have been provided with and she appears content at Bowles
Lodge.
4.12.1
4.12.2 It would be my recommendation that she remains at Bowles Lodge Care Home.
The only question I would raise is that as I have now made a diagnosis of
dementia whether Bowles Lodge actually has the status to look after patients
with dementia, i.e. is registered for patients with dementia. If not, then a
694.;;1Font color: Black
694.;;1Font: verdana
694.;;1Font: Bold
22
On: Vera Waylor
_________________________________________________________________________

variation could be applied for with the CQC which can occur if patients are felt to
be placed and adequately looked after.

4.12.3 If Mrs Waylor is to be moved despite the clear risks, she will need a dependency
rating and KCC have a policy for this. This would be a joint assessment. This
would benefit from involvement by a care manager, possibly a Registered Mental
Nurse/Community Psychiatric Nurse due to her dementia and possibly also a
practice nurse due to her physical health and this would need to be carefully
managed with the input of her treating General Practitioner to make sure that
her delicate state, both from a mental and physical perspective, is not
decompensated by the stress of transfer. Despite any intervention to mitigate
any risk, the risks would remain and on the balance of probabilities transfer in
my opinion would shorten her lifespan to 6-12 months from date of transfer.

4.12.4 I have not been provided with any documents to suggest that this has been
adequately considered by those providing care for Mrs Waylor and the local
authority has a responsibility to ensure this happens if it insists on transfer. This
also requires a risk assessment.

4.12.5 Her physicians opinion about the impact of stress on her cardiac decompensation
would also be advisable.

5. Statement of compliance

I understand my duty as an expert witness is to the court. I have
complied with that duty and will continue to comply with that duty. This report
includes all matter relevant to the issues on which my expert evidence is given.
I have given details in this report of any matters which might affect the validity
of this report. I have addressed this report to the court.

6. Statement of truth
6. I understand that my duty is to the court and this is to confirm that I have
complied with that duty. I am aware of the requirements of Part 35 and Practice
694.;;1Tab stops: Not at 0.S"
numbering, Tab stops: Not at 0.76" + 0.73"
23
On: Vera Waylor
_________________________________________________________________________

Direction 35, and the practice direction on pre-action conduct. I confirm that I
have made clear which facts and matters referred to in this report are within my
own knowledge and which are not. Those that are within my own knowledge I
confirm to be true. The opinions I have expressed represent my true and
complete professional opinions on the matters to which they refer.
I understand that my duty is to the court and this is to confirm that I have
complied with that duty. I am aware of the requirements of Part 35 and Practice
Direction 35, and the practice direction on pre-action conduct. I confirm that I
have made clear which facts and matters referred to in this report are within my
own knowledge and which are not. Those that are within my own knowledge I
confirm to be true. The opinions I have expressed represent my true and
complete professional opinions on the matters to which they refer.

Signed: ................ Date: ....
Dr. G C Fox, Consultant Psychiatrist
Norwich Medical School
University of East Anglia
Norfolk
NR4 7TJ

694.;;1Normal
694.;;1Normal, ]ustified
694.;;1]ustified, Line spacing: 1.S lines

DR Fox Report

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

DR Fox Report

Загружено:

Авторское право:

Доступные форматы

CONFIDENTIAL

Вам также может понравиться