BASILDON Hospital is once again in the firing line following the death of patient it discharged - the hospital is criticised by a coroner who says it failed to offer 'even the most basic nursing care'.

Severely-ill Ronald Ashdown, a resident at a Grays care home, was discharged back to the home with his genitals covered in a white "cheese" and died days later.

Area coroner for Essex Sean Horstead has now ruled that 55-year-old Mr Ashdown's treatment at the hospital revealed "a serious failure in the provision of the most basic of nursing care".

He also has castigated the Mid and South Essex NHS Foundation Trust that runs the hospital for providing a report into the matter that initially wrongly shifted blame away from the trust.

Mr Ashdown had been left severely disabled following a cardiac arrest and subsequent significant hypoxic brain injury he suffered in 2013. Over subsequent years he lived at the Coach House Nursing Home on Woodward Close in Grays.

He had been admitted to Basildon University Hospita on July 6, 2021 with shortness of breath, cough and fever and treated with antibiotics for aspiration pneumonia. He was discharged back to the care of the nursing home on August 2, 2021.

The Coach House Care Home.

It was then staff raised a safeguarding concern after finding his genitals covered in a white "cheese" like substance and faecal matter in his pubic hair – sending photographic proof to the trust.

He was readmitted to the hospital on August 12 after dislodging a feeding tube. He died three days later on August 15 which the coroner has conceded was not related to the safeguarding concerns raised by the nursing home.

But the coroner has subsequently ruled that the Trust carried out a significantly flawed root cause analysis (RCA) investigation into the nursing home's concerns which he said effectively rejected any suggestions of shortcoming in care, management and treatment.

The ward matron responsible for the ward concerned, who was the co-author responsible for the RCA report, said she had not been provided with the photographs provided by the nursing home and Mr Ashdown's daughter until just two weeks prior to the inquest hearing.

The trust's responsible Adult Safeguarding Lead said that notwithstanding the photos having been expressly noted in the original safeguarding referral and raised in subsequent correspondence and meetings with the Thurrock Local Authority Safeguarding Team, the trust had not made the photos available.

The coroner added in his prevention of future deaths report: "This lack of professionalism was and remains a grave cause for concern resulting as it did in a seriously flawed trust investigation."

The evidence heard at the inquest the patient had extensive flakes of fungal growth behind his ears and his foreskin/genitals were covered in flakes and what appeared to be "cheese / paste even though the RCA concluded there was none of this

Even though his pubic hair contained dried faecal matter the RCA asserted that he had a full wash on day of discharge back to nursing home.

Having belatedly considered the photographs, the ward matron retracted her investigation findings and conceded that for his genitals to have appeared as they did in the photographs he would have had to have received "no basic nursing care in the form of the washing of his genital area for several days".

The extensive areas of flaking skin behind RA's ears were also, contrary to the RCA finding, now accepted.

Area coroner Sean Horstead delivered a damning verdict on Basildon Hospital and the Trust that runs it.

The coroner added: "The extent of the Trust's inexplicable failure to provide critical primary evidence for the purposes of the RCA led directly to an erroneously exculpatory RCA Report; without an accurate and reliable RCA the lessons upon which important changes to trust systems and practice depend cannot be identified and acted upon in a timely fashion.

"The evidence confirmed that, despite his clear vulnerability and complete physical dependence on trust staff providing basic nursing care, including simple personal hygiene, Mr Ashdown did not receive such basic care for an extended period – probably over several days.

"This does not indicate, as appears to have been suggested at one point by the trust, a failure in record keeping but, rather, a serious failure in the provision of the most basic of nursing care.

"Running as it did over several days, the evidence confirmed that this failure to provide basic care likely extended beyond one or two members of staff and, further, was simply not picked up by the more senior nurses on the ward.

"Although the failure to provide such basic nursing care, in the specific context of Mr Ashdown's identified cause of death (and notwithstanding his vulnerability to infection), had no causal relevance to his death, I am nonetheless entirely satisfied that in myriad other cases the identified failure of this kind gives rise to the obvious risk of infection and consequently the risk of future death."

Denise Townsend, Deputy Chief Nursing Officer for Mid and South Essex NHS Foundation Trust, said: "Providing the best possible patient care is our absolute priority, but we are not able to discuss the particulars of this case whilst the investigation is still on-going."