A family man who would treat local children to ice cream died partly due to failures and neglect by Great Western Hospital.

An inquest on November 8 heard Maurice Small “lost the will to live” as a result of repeated visits to GWH for health problems.

A coroner stated that "complete and total" failures by GWH to arrange appointments and neglect also directly led to his death on July 29, 2023, aged 81.

His daughter, Mandy Gibson, said: “Maurice was very much a family man, especially towards his three granddaughters, who loved him a great deal.(Image: Newsquest)

“He always took a fond interest in everything we did and provided loads of encouragement to all of us.

“He was regularly seen walking up and down the street where he lived with his toolbox, going to fix something in a neighbour's house.

“If he did not have his toolbox, he'd be carrying a cake or pie he had made for someone, or ice cream for children playing in the street. 

“Everybody knew him and looked out for him.”

Maurice was born on April 28, 1942, the youngest of eight and had a tough childhood after his father died when he was four. However, he loved sport, trialling for the Olympic swimming team.

Living on Poulton Street in Swindon he was the sole carer for his wife in her last years, ran the neighbourhood watch and set up a community project for lonely widowers and widows.

He became too ill to see the project through.

Morris had major bowel surgery in November 2022 and developed repeated respiratory issues including pneumothoraxes, a collapsed lung.

He got an empyema, a pocket of pus in the body cavity, in April 2023 and was discharged from GWH on May 1, 2023.

His condition improved after an antibiotic course, but he relapsed in July 2023 which ultimately led to his death. 

HM senior coroner, David Ridley, said: “Whilst it was hoped Morris would make a full recovery, he had lost the will to live and he was unable to recover from the disease.”

He said that four failures contributed to Maurice’s death.

The first was a failure to send a discharge letter to his GP, alerting them of Maurice’s readmission.(Image: Matt Meader-Harris)

Secondly and thirdly, a failure to arrange a follow-up appointment and a follow-up chest X-ray after the antibiotic course to check if the infection was cured.

Fourth, the missing X-ray appointment was noticed and an X-ray was requested - “but no appointment was set. Maurice’s death was contributed to by neglect," said Mr Ridley. 

He added: "This does appear to be more likely than not a gross failure to provide basic medical attention.

"That basic medical attention is a further set of antibiotics.

"There was a significant failing, complete and total failing, in terms of notifying a GP, combined with the appointment, follow-up appointment, including the chest x-ray, that I have to say more likely than not would have resulted in Morris not dying when he died."

Ridley ended: “I would like to sincerely offer my condolences to his daughter and other family members in relation to the untimely loss of Maurice at the end of July last year.”

A spokesperson for Great Western Hospitals NHS Foundation Trust said: “We continue to offer our sympathies and condolences to Mr Small’s family and friends following his sad death.

“We are sorry that Mr Small’s care fell short of the standard we strive to deliver, and that key diagnostic and follow-up opportunities in his care were missed.

“Since Mr Small’s death, we have made a number of improvements to prevent anything similar from occurring and we will also soon be moving from our previous electronic discharge system to a new digital tool which will ensure a better process for handover of care from one organisation to another.

"Additionally, we have secured investment for a new shared electronic patient record across Bath and North East Somerset, Swindon and Wiltshire.

“The learnings from Mr Small’s case continue to be shared at teaching events and patient safety meetings, to illustrate the importance of accurate and timely information sharing between all those who are providing a patient’s care.”

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