Peter Dervin had spent all day by his son’s side in Broomfield Hospital before he decided to get dinner.
He pleaded with staff at the Essex facility not to leave his eldest child, Greg, alone in his absence.
« They almost laughed at me and said, ‘This is what we do. We’re nurses and we look after patients’, » Dervin recalls.
Greg had been given lorazepam, an anxiety drug flagged by clinicians as leaving him prone to becoming unsteady and agitated.
When his dad returned to the ward a short while later, Greg was in a critical condition.
Left alone in his room, the 35-year-old had fallen over and hit his head on a piece of equipment, causing a catastrophic brain injury.
Greg, a father, structural engineer and Arsenal fan from Roxwell, near Chelmsford, died a week later, on 10 May 2024.
A four-day inquest at Essex Coroner’s Court found on Tuesday that neglect by the Mid and South Essex NHS Foundation Trust contributed to his death.
« Greg was my first son and the person who made me walk taller and be a good person, » says Dervin, who lives in Broomfield, near Chelmsford.
« He was going to be an amazing dad. It didn’t turn out that way and we’re all sad because of that. »
Greg was being treated for a heart issue brought on by what his family branded « mismanagement » of his Crohn’s disease.
He was transferred from a London hospital to Broomfield on 23 April 2024 and had been on track to be discharged after almost 500 days of treatment.
Area coroner Sonia Hayes said he arrived in Essex with a « significant, comprehensive discharge plan » that included two-to-one care.
But those dedicated nurses were removed by Broomfield and replaced by a security guard, whose task was to watch Greg from outside his room.
That guard, Olufemi Oyedeji, was not permitted to make clinical interventions and so could not help Greg – despite having seen him fall numerous times before his fatal plunge.
Those falls should have been referred to the trust’s falls team but were not, the inquest was told.
Hayes said it was a « gross failure » by the hospital to have decided Greg needed close supervision but instead employ someone who could not fulfil the role.
« He had to watch my son fall and die through a door because he wasn’t allowed in the room, » Dervin said.
It was also questioned at the inquest whether a security guard was appropriate, considering Greg had been assaulted by one at a different hospital.
Hayes said many of the assessments about Greg were « riddled with inaccuracies ».
One stated he did not have a neurological deficit, despite him spending more than 450 days at the National Hospital for Neurology and Neurosurgery in London.
But perhaps the key error was staff failing to notice Greg had « a very particular sensitivity to lorazepam ».
On the day of his fall on 3 May 2024, he had been given the drug ahead of a CT scan.
Dervin says he warned the nurses: « We’ve been looking after him for more than a year in hospital and lorazepam has affected him massively every time – look after him. »
When Greg’s dad went to get his food, he told them to call him if there were any problems.
He explains: « I came back a few hours later to find him in bed with a massive cut on the back of his head and unconscious.
« That’s the last time I ever spoke to him. It ripped my heart out.
« If they hadn’t said they would look after him, I wouldn’t have gone home. I would’ve stayed because I knew what lorazepam was like for him. »
During the inquest, Hayes accused the hospital trust of intentionally withholding key information from her.
Staff had told her no first-hand report was written about the incident, but it later emerged that was not true.
Instead, whoever prepared the hospital’s evidence for the inquest had not clicked on drop-down boxes online to reveal it.
Hayes said she was « shocked and disappointed ». The hospital’s lawyer said it was « unacceptable » – but denied it was intentional.
« The process has been horrendous, all they’ve done is not be honest with us, » Dervin says.
He claims hospital leaders denied the family bereavement support because Greg died at Addenbrooke’s Hospital, Cambridge, where he was transferred after the fall.
« When your son has just died, for a hospital to say ‘We don’t owe you a duty of care at all’ is just the worst, » Dervin adds.
Greg was just about to start an engineering consultancy when he went into hospital.
Described by his dad as « a good person », he loved spending time with his younger brothers
Dervin continues: « It feels like something’s missing, and that’s a massive hole. If this was the only kid I had, I’d find it hard to wake up in the morning. »
The family hope lessons will be learned so no-one else has to experience what they have gone through.
« People go into hospital and some people die. People get ill and die, » Dervin says.
« But people shouldn’t go into hospital and not be cared about. »
The hospital trust said Dervin’s case was « particularly complex » and finding all the evidence had been challenging.
Sharon McNally, its chief nursing officer, said: « We’d like to reiterate our condolences to Mr Dervin’s family, who have been kept regularly updated on the progress of our investigation throughout.
« A full multi-disciplinary review was completed, and learning and improvements have been made to help reduce the future chance of falls with harm. »
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