Grace’s story – a family’s experience of the inquest process
Becky Randel, Senior Associate in our Inquests team, supported Grace Horton and her family at the inquest into the death of her son Declan.
Declan was a 27-year-old man who suffered from cerebral palsy, epilepsy, autism and was PEG fed. He lived at Holly Lodge, a nursing home supporting those with learning difficulties and health issues. Declan was admitted to Great Western Hospital (GWH) in Swindon due to increased seizures. He was treated for an infection, but during his admission, due to a medication error, his anti-epilepsy medication was halved.
Despite a pharmacist raising this issue with a treating doctor, the warning was ignored and Declan’s usual medication was not reinstated. When he was discharged home, he suffered from increased seizures and had to be re-admitted to GWH just five days later where again, issues with his epilepsy medication meant that it was not administered in the correct dosages. His seizures continued and he suffered from aspiration pneumonia from which he was unable to recover and he sadly died six days after admission.
Grace had watched her son’s deterioration and last, distressing moments in hospital and was determined to get justice for him and find out what happened. This included fighting to get a post mortem, which she had to obtain privately, although an extremely kind pathologist waived the fee for her.
Grace first sought the help of RWK Goodman in May 2023, just over a year after her son’s death. Due to long delays in the Coroner’s court, Grace had to wait until February this year to have her son’s inquest heard. We were able to voice Grace’s concerns and question those who were involved with his care to find out why mistakes were made and how Declan died.
Grace has shared Declan’s story to help others who are facing an inquest hearing after the death of a loved one.
Tell us about Declan, who he was and what happened before he died.
Declan was the bravest, strongest person I know.
He was, and still is, loved, cherished and missed by all his family and friends. He was the light to his family’s life and the most precious person you could have asked for.
Before Declan was admitted to hospital, he was happy, content and well. He was looked after by the most caring care home there was.
When did you become concerned about the treatment Declan received in hospital and how he had died?
I first went to PALS (PALS is the Patient Advice and Liaison Service available at all hospitals for concerns or complaints) because I did not understand how I had left Declan at the hospital on a Friday night when he had been fine, and then on the Saturday morning, I was told he might be dying. He had deteriorated so quickly after we had been told there were plans for him to be discharged, I did not know what had gone wrong. I also complained because there was a lack of communication with our family regarding his health and how he was doing whilst admitted. There was also the concern about the pain that Declan suffered in his last moments, which the whole family had witnessed and been very distressed by. This was beyond acceptable to us.
Declan was a complicated patient and had a number of health issues, but I felt like the nurses and doctors didn’t have much interest in actually knowing who Declan was. Everything felt very rushed with his treatment and on multiple occasions, as a family, we felt that they just did not have enough time to understand Declan or treat him properly.
What made you decide to try and get legal representation?
I got in touch with a charity called INQUEST and they put me in touch with RWK Goodman. I wanted someone to help us investigate the lack of care Declan was given and the fact that, in just a week or so, he went from being fine and being told he could go home to then fighting for every last breath.
How did you find having a legal team on board at the inquest?
The legal team have been nothing but supportive and caring and considerate and friendly throughout the whole process. I would definitely recommend Becky and the team to other families who have gone through what we have.
I was very pleased I had legal representation at the inquest because it helped me cope and understand the process and on the day made the inquest seem less daunting as I had support there. Also, beforehand it helped me mentally prepare and I knew what to expect every step of the way.
Is there anything you wish you had known before you went through the inquest process that you think other families should know?
I wish I could have known how long it would be before we had the inquest. The length of time it has taken to get to the inquest, which was four years in Declan’s case, was long and hard on the whole family.
Also, the way the final conclusion is given by the Coroner may not be told in language that is easy to understand. We felt that this needed to be interpreted by our legal team for us. I wish they had made it more accessible for us as a family.
You can read more about Declan’s inquest in the press reports here.
Have a question about the inquest process?
Contact Becky.
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