Family told man who died might have survived if Leicester NHS staff reacted more quickly

Staff at a mental health unit failed to act quickly enough to save a patient who died after he was found lying face down on the floor of his room, a coroner has ruled.

Dan Dryden, 32, was admitted to the Agnes Unit in Anstey Lane, Leicester, which run by the Leicestershire Partnership NHS Trust (LPT), for a review of his medication on August 24, 2018.

He then deteriorated and was found collapsed in his room on 28 August - 17 minutes after staff checked on him.

Mr Dryden was then rushed to Leicester Royal Infirmary - but died later this morning despite attempts to resuscitate him.

An inquest into his death heard Mr Dryden had suffered a head injury and cardiac arrest.

Ivan Cartwright, coroner for Leicester and Leicestershire South, said the unit missed an opportunity to potentially save his life by not calling paramedics sooner.

Mr Dryden's family have now issued a statement which says: "Dan went into the Agnes Unit for a medication review with devastating results."

'This has been a long painful journey that no other family should have to experience'

His family added: "We assumed that he would have been safe and cared for adequately but this was clearly not the case.

"This has been a long painful journey that no other family should have to experience."The inquest heard Mr Dryden had become increasingly confused and agitated every day that he was in the Agnes Unit.

The inquest heard he had suffered "multiple head impacts" and a serious traumatic brain injury the day before he died, but staff did not carry out any neurological or physical observations after the incident.Staff then helped him into a chair and gave him medication at 9.20am on the day he died, but was then not closely monitored. He was then found on the then found on the floor at 9.37am and was not responsive.

Mr Cartwright said he "should have been watched more carefully" by staff at the unit, who should have put him into the recovery position and called paramedics sooner than they did.The inquest was also told on the balance of probabilities, the situation would have had a better outcome for Mr Dryden if staff had intervened sooner.

Recording a narrative verdict, the coroner said Mr Dryden died due to "positional asphyxia" and a "head injury".The family were represented by Kelly Darlington and the Inquests team at Farleys Solicitors and Chloe Murray of Cobden House Chambers.

A spokesman for Leicestershire Partnership NHS Trust said: "We would like to express our deepest condolences to Daniel’s family and friends.

"Daniel had complex physical and mental health needs; we carried out a full investigation following his death in 2018 and made a number of changes.

"We have been fully involved with the recent inquest which concluded on 14 October 2022, and fully accept the narrative conclusion returned by the Coroner."