Part of the reason for the delay is that witness statements hadn't been taken - presumably the hospital didn't realise there was a problem.
Not taking statements mean the honest people forget what happened and dishonest people have a chance to get their stories straight.
To put it simple, Mr Phelan went to A and E suffering from alcohol withdrawal - it's very dangerous and often life threatening.
He was seen (probably after a long wait) and triaged. That means his problem was evaluated and he was admitted, then left to wait.
At some point he left before he was treated - and not found for a week! By which time his body was discovered on the dual carriageway outside the hospital.
Here's the report from 'Get Surrey';
Family of missing man found dead near St Peter's Hospital suggest 'systemic failings' at A&E
By Charlotte Tobitt
James Phelan was found dead near the hospital seven days after seeing a doctor in A&E when suffering from acute alcohol withdrawal
The family of a Walton man who was found dead seven days after going missing from St Peter’s Hospital has suggested there are "systemic failings" in how patients are assessed when they first attend A&E.
James Phelan was suffering acute alcohol withdrawal when he visited A&E at the Chertsey hospital on Friday August 8 2014.
After being taken to hospital by ambulance, Mr Phelan had been seen by a triage nurse and was waiting to be seen by a doctor before deciding to discharge himself. He was found dead nearby seven days later.
A pre-inquest review was held at Woking Coroner’s Court on Monday (September 19) where Rachael Marcus, representing Mr Phelan’s family, insisted the inquest into his death should investigate systemic failings into the triage system at St Peter’s Hospital.
The court heard Mr Phelan had been triaged as an unwell adult rather than under a mental health category, despite acute alcohol withdrawal being a crossover mental and physical complaint.
Ms Marcus told the court acute alcohol withdrawal is a "widespread issue" but that the Manchester triage system employed by the hospital is inadequate in these cases.
“The triage system in place at this trust was not adequate to deal with the situation in which Mr Phelan found himself,” Ms Marcus added.
“There is a potential for a systems issue in place, whether at this particular trust or whether it is a nationwide problem.”
The court heard St Peter’s Hospital has now produced a draft policy for the treatment of alcohol withdrawal and alcohol dependency which was not in place at the time of Mr Phelan’s admittance.
Ms Marcus questioned whether Ashford and St. Peter’s Hospitals NHS Foundation Trust was "behind in its thinking according to what was accepted thinking in 2014
However coroner Darren Stewart said: “We may not be in a place of systemic failings.”
He added: “He [Mr Phelan] may just not have been triaged properly as opposed to the triage system itself being a problem.”
Mr Stewart also said it was a busy night for the hospital and Mr Phelan may not have been seen any quicker even if he was triaged differently.
Ms Marcus had also appealed to Mr Stewart for the process to be treated as an "article two inquest", which is given in circumstances where the state or "its agents" have "failed to protect the deceased against a human threat or other risk".
But Mr Stewart said on Monday: “This court is not a place to engage in an exercise seeking to improve the National Health Service.”
He added that if the court found systemic failings had contributed to Mr Phelan’s death, the inquiry could then be expanded and he would keep open the possibility of engaging article two.
A full inquest into Mr Phelan’s death is due to be heard later this year.
James Phelan was suffering acute alcohol withdrawal when he visited A&E at the Chertsey hospital on Friday August 8 2014.
After being taken to hospital by ambulance, Mr Phelan had been seen by a triage nurse and was waiting to be seen by a doctor before deciding to discharge himself. He was found dead nearby seven days later.
A pre-inquest review was held at Woking Coroner’s Court on Monday (September 19) where Rachael Marcus, representing Mr Phelan’s family, insisted the inquest into his death should investigate systemic failings into the triage system at St Peter’s Hospital.
The court heard Mr Phelan had been triaged as an unwell adult rather than under a mental health category, despite acute alcohol withdrawal being a crossover mental and physical complaint.
Ms Marcus told the court acute alcohol withdrawal is a "widespread issue" but that the Manchester triage system employed by the hospital is inadequate in these cases.
“The triage system in place at this trust was not adequate to deal with the situation in which Mr Phelan found himself,” Ms Marcus added.
“There is a potential for a systems issue in place, whether at this particular trust or whether it is a nationwide problem.”
The court heard St Peter’s Hospital has now produced a draft policy for the treatment of alcohol withdrawal and alcohol dependency which was not in place at the time of Mr Phelan’s admittance.
Ms Marcus questioned whether Ashford and St. Peter’s Hospitals NHS Foundation Trust was "behind in its thinking according to what was accepted thinking in 2014
However coroner Darren Stewart said: “We may not be in a place of systemic failings.”
He added: “He [Mr Phelan] may just not have been triaged properly as opposed to the triage system itself being a problem.”
Mr Stewart also said it was a busy night for the hospital and Mr Phelan may not have been seen any quicker even if he was triaged differently.
Ms Marcus had also appealed to Mr Stewart for the process to be treated as an "article two inquest", which is given in circumstances where the state or "its agents" have "failed to protect the deceased against a human threat or other risk".
But Mr Stewart said on Monday: “This court is not a place to engage in an exercise seeking to improve the National Health Service.”
He added that if the court found systemic failings had contributed to Mr Phelan’s death, the inquiry could then be expanded and he would keep open the possibility of engaging article two.
A full inquest into Mr Phelan’s death is due to be heard later this year.
I can't say I'm happy about the attitude of the Coroner - I'll probably have more to say about that when we have the final report of the inquest.
In particular I'm very concerned about his statement that; “We may not be in a place of systemic failings".
I actually think there are systematic problems about how vulnerable people are treated, because on May 16th this year Jack Barker (a patient at St. Peter's) also disappeared from the same hospital and was only found 2 weeks later on May 31st.
Luckily he was still alive.
And to say; “This court is not a place to engage in an exercise seeking to improve the National Health Service.”
is very worrying because when someone dies as a result of problems at an NHS Hospital there is no other way of holding the hospital trust to account.
Neil Harris
(a don't stop till you drop production)
Home: helpmesortoutstpeters.blogspot.com
Contact me: neilwithpromisestokeep@gmail.com
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