CORONER QUESTIONS SERVICES FOLLOWING DEATH OF RECLUSE

These included Sussex Police, Little Common surgery, and East Sussex County Council’s Social Care Department (SCD).

Jacqueline Sexton of Millham Close was a recluse who died on her own at home having shunned help from police officers and paramedics called out by an alert milkman who “knew something was wrong” when she didn’t take in her delivery.

Coroner Alan Craze held an investigation to question procedure following that initial contact on Friday August 15 2008 and stated though the outcome would doubtless have been the same, Miss Sexton could have been more comfortable during those last days with the help of palliative care.

He worried she had slipped through the safety net in terms of action by relevant agencies and wanted to check safeguards had been put in place to avoid the same happening again.

The inquest heard how the deceased was a loner who would hide from neighbours rather than talk to them and hardly ever went out except for food shopping once or twice a month. She had once been a legal secretary but stopped work to look after her mother when her father died in 1987. Her mother died in 1989 and after that Miss Sexton gradually stopped going out.

There was never a light on in her house and other residents in the street had no contact.

The only regular visitor was milkman Peter Robertson who had delivered to her for nine years but never once met face-to-face because his round was so early.

On Wednesday August 13 he noticed for the first time ever that Miss Sexton had left no payment for him.

On Friday he returned and found still no money while milk from Wednesday had not been taken in. He completed his round then called the police.

Four officers arrived within 20 minutes and two of them knocked on the front door and windows while two went round the back.

After a while Miss Sexton leaned out of the upstairs bedroom window and began telling them to go away.

She was described as thin and frail later by all the officers who thought her much older than she was – PC Rachel Harrison guessed Miss Sexton to be in her early-to-mid 80s.

PC Grant Holman tried to talk to Miss Sexton who refused to let them in and repeatedly asked to be allowed to go and lie down.

She claimed she had been ill for a few days but that she had food next to the bed and wanted to be left alone.

Neighbour Gary Deans heard this exchange and said: “She looked ill and gaunt and was clearly not in her right mind.”

He also commented that she sounded “like a wounded animal.”

His wife Shirley was not there at the time but emailed social services later to express concern that Miss Sexton needed help.

A call was made by the police to track down her GP but a receptionist at Little Common surgery said the doctor was not available and that request was abandoned.

PC Holman contacted the ambulance service while PC Matt Morris talked to her, and when paramedics arrived they had the same response from Miss Sexton who would not let them in and told them to go away.

The ambulance crew judged her to be not at immediate risk and decided to stand down as did the police who felt she was fully coherent and communicating clearly.

PC Holman was tasked with following up the case with SCD and emailed details at 4pm before going off duty.

Twelve days later the milkman raised the alarm again on Wednesday August 27 when he realised Miss Sexton had not taken any of the milk he delivered.

PC Steven Prince broke a back window to gain entry to the house where he found all doors locked inside and a bath full of incontinence pads.

He found the deceased’s emaciated and decomposing body on the bed with the front door key still in her hand.

At Hastings law court this week Mr Craze examined how the follow-up process to the first contact had failed in several places – by PC Holman not taking up emailed suggestions from SCD for achieving referral to mental health, by the adviser from SCD who did not record any details of the case received by her, and also the GP surgery where the receptionist had not taken note of the call from police.

Dr Lindsay Hadley from the practice told the inquest that Miss Sexton had last seen a doctor in 1998 and never telephoned or made an appointment since.

She agreed that the receptionist had not followed appropriate procedure and that a community nurse could have visited the next day to make contact with the patient.

Mr Craze commented: “This is a case that makes one uneasy because in the 21st century one doesn’t like to think of anyone dying what must have been a painful death entirely alone in the way this has happened.”

The subject of mental capacity was one the coroner returned to repeatedly as he discussed the case with all those concerned, questioning if Miss Sexton was well enough to make the decision to refuse treatment, or whether this should have been taken out of her hands.

He felt that the emergency services, in this case police and paramedics, were responders on the front line, but that the GP was the “gateway” or “gatehouse keeper” for the process, with social services taking on the “pivotal role” in the care of vulnerable individuals with the ultimate job of co-ordinating a multi-agency response if required.

Assistant director of Adult Social Care Department Mark Stainton told the inquest how an internal review had been held following “concerns about the quality of our response” and that an action plan had been drawn up to ensure mistakes would not be repeated.

This included regular monitoring of calls, with all contacts and actions recorded, increased supervisory input, and feedback, as well as new procedure for vulnerable adult referral.

Both police and the ambulance service also reported that changes in procedure had been made in the period following Miss Sexton’s death to alert attention to vulnerable adults.

The coroner returned a verdict of death by natural causes and said of those involved: “I am very pleased indeed that there have been improvements, which to my mind carry with them a massive amount of common sense, and I can only wish each one of these changes well in the future and hope these protocols will assist in extremely difficult tasks which we the public give them to do.

“No-one will deny Miss Sexton gave them a difficult situation to deal with.”