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The Inquest into the death of James Phelan.

It's been a long time coming and I suspect the family of the late James Phelan will be disappointed by the outcome of the inquest. Three and a half years is too long to wait for an investigation into a death and that is probably The Coroner's Courts fault.

I've commented before on preliminary comments made by the Assistant Coroner which pretty much determined the outcome of this hearing, but I'll run through them again here.

James Phelan was an alcoholic who had stopped drinking and attended St. Peter's Accident and Emergency after suffering from the terrible symptoms you can suffer when you do this.

It certainly wasn't his 'fault' that he was ill, he was trying to do something about his illness and needed our support. 

There was a delay in seeing him with the result that he discharged himself from the Hospital.

He then disappeared for a week and was only found after a massive Police Search - he had walked out of the hospital and died in severe weather conditions a matter of half a mile away on the side of a main road.

Here's the Inquest findings as reported in 'Get Surrey';
A Chertsey hospital which allowed a detoxing alcoholic to discharge himself failed to provide vital details that would have helped police after he was reporting missing by a nurse, an inquest heard.

James Phelan, 42, died of alcoholic ketoacidosis when he discharged himself from St Peter's Hospital after paramedics had taken him there from his Hersham home on August 8 2014.


Woking Coroner's Court heard on Friday (January 19) that he never returned home.


Assistant coroner Darren Stewart found there to be three failings by St Peter's Hospital accident and emergency (A&E) staff when dealing with Mr Phelan.

The first was the failure of an "inexperienced" nurse and the Manchester triage system used, which should have correctly labelled Mr Phelan's case as "yellow" and that he "should have seen a doctor within the first hour of his admission", the court heard.  

Second was Sister Patterson's failure to provide a detailed explanation into the consequences if Mr Phelan successfully discharged himself from hospital.


And third, the assistant coroner mentioned how hospital staff in the A&E department failed to provide "vital information" to assist in Surrey Police's search for Mr Phelan.

He ruled out neglect on all three as "there are too many avenues at a certain period in terms of what would have happened next".

Drinking was a 'coping mechanism'

The father-of-two turned to drink as a "coping mechanism" following the death of his brother in 2010 which had an "impact" on him, the court heard.

After moving from Horsham to Weybridge and being made redundant after the financial crisis, Mr Phelan consumed two to three bottles of vodka a week, the inquest heard.

Mr Phelan, who worked as a banker, was taken into hospital on August 8 2014 when he showed alcohol withdrawal symptoms after taking a detox just four days earlier.

Before then, he complained about hallucinations and his neighbour mentioned how she saw him in the garden "as if he was talking to someone there".

When paramedics arrived he was adamant that the family should be absent while he disclosed symptoms and medical information.

At St Peter's Hospital, he was placed as a "green" patient, meaning he was the lowest priority patient in the A&E department.

Once he discharged himself, Sister Patterson rang his partner to notify her that he had discharged himself at 7.08pm and made his way home in "thunderstorm" conditions, the inquest heard.

More than an hour later, police were called after the same nurse reported him missing - he was labelled as "medium" risk.

The inquest heard how a deeper look into Mr Phelan's condition - which was not initially disclosed to the force - made him a "high" risk the following day.

The "high risk" meant that police were able to use the help of Surrey Search and Rescue and helicopter units.


After a week's search, Mr Phelan's body was found under a bramble near Abbey Moore golf course along St Peter's Way.

'Extremely generous, kind, witty and intelligent'


A post-mortem examination revealed Mr Phelan would have died between August 8-9 2014.

When he concluded the inquest, Mr Stewart paid tribute to Mr Phelan, calling him "extremely generous, kind, witty, and intelligent". He praised Mr Phelan's family and loved ones for their "patience and diligence".

So what's wrong with that?

First, and perhaps most seriously, a hospital should be proactive when a patient disappears in bad weather and seek to dissuade them from leaving until they have been seen by a Doctor.

In fact, the Inquest had to be postponed due to the failure to take adequate witness statements near the time of the death, which means it is very unlikely that the paperwork is in order or that discharge procedures were actually followed at all.

Secondly, it speaks very badly to security at the hospital that an ill, disorientated patient can just walk out - it means that anyone can walk in by the same method. Which places all patients in danger and hospital property at risk.

The failure to warn the Police properly prevented a suitably urgent search to be carried out while there was still time to find Mr Phelan alive.

My real concern is that the Assistant Coroner made it clear from the beginning that he would be unwilling to issue a statutory notice to the Hospital that it had placed a life at risk and would need to change it's procedures to ensure that this did not happen again.

This prejudged the outcome of the hearing. Even though he highlighted three areas of concern he concluded that this did not amount to 'neglect'.

To me, if you take what happened as a whole, it amounted to a system that was defective in dealing with disoriented and distressed patients.

People suffering from Alcohol withdrawal symptoms are frequent attenders at A and E's - they are seriously ill and often die as a result of their illness. A failure to adequately care for them means that this situation will recur - other lives will be lost unless changes are made.

The same applies to any disorientated patient suffering from Alzheimers Disease, Dementia, Mental Illness as well as many forms of addiction.

It has to be a matter of concern.

Neil Harris
(a don't stop till you drop production)
Contact me: [email protected]

This post first appeared on Help Me Sort Out St Peter's!, please read the originial post: here

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The Inquest into the death of James Phelan.


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