A homelessness campaigner died because of neglect following a catalogue of errors by healthcare professionals, a coroner has concluded.

Wayne Lammond, 36, died after his brain was starved of oxygen following a cardiac arrest, but an inquest jury heard that medical staff failed to carry out a series of medical checks and actions that could have saved his life.

A jury at the 12 day inquest found that neglect contributed to his death – an extremely rare conclusion which can only be used where there has been a gross failure to provide basic medical attention and that this caused an individual’s death. 

Wayne’s family instructed the specialist Inquests and Civil Liberties team at Broudie Jackson Canter to represent them at the inquest.

Wayne, who suffered from paranoid schizophrenia, was taken to the Countess of Chester Hospital’s accident and emergency department on 20 November 2021, after his sister called an ambulance on the 19 due to concerns following a deterioration in his mental health.

Wayne, who was agitated and confused, was restrained and taken to the ground by police and security staff at the hospital four times in 25 minutes before he was admitted.

The jury at the Cheshire Coroner’s Court was shown a Body Worn Video (BWV) of the moments before Wayne died in which he made a strange rattling noise and stopped breathing.

A police officer from Cheshire Constabulary admitted he had noticed Wayne had stopped breathing, but did not call a nurse as he assumed they were watching.

To compound matters, a nurse who attended his bedside also initially failed to notice that Wayne had stopped breathing. It was only when she returned to deliver a sedative injection that staff reacted, and he was taken to the resuscitation area.

The inquest heard expert medical evidence from Dr Jasmeet Soar, an emergency care doctor, who reviewed the BWV of the resuscitation attempts and said that basic checks such as blood pressure and other vital signs were not carried out while he was in the resuscitation area.

Wayne was connected to an automatic defibrillator and the footage revealed that it prompted medical staff to give Wayne an electric shock to restart his heart, but none was given.

Dr Soar said Wayne was left without treatment for 14 minutes, starving his brain of oxygen and resulting in a fatal brain injury.

Wayne’s younger sister Ann Mawdsley said: “I miss Wayne more than anyone could ever understand. He was more than just a brother; he was my best friend. Wayne deserved to be treated with respect and receive the medical assistance that could have saved his life.

“This could not have been further from the reality that our brother endured in his final hours. Instead of competent medical care Wayne was restrained four times, which would have been extremely distressing for him in his mental state, and then failed to receive even the basic care and attention he needed.”

Wayne’s sister Natasha Walker added “While nothing will bring Wayne back, we are grateful to the jury and the coroner for their finding that neglect contributed towards his death and hope no other families are forced to endure the trauma that we have. The fact we have not received an apology from anyone involved continues to add to the trauma, as well as the difficulties we had in finding out the truth over the last three years.”

Nicola Miller, a solicitor from Broudie Jackson Canter who represents Wayne’s family, said: “Wayne’s family is understandably devastated to have heard that his life could have been saved if it wasn’t for the failures of those responsible for his care. While we are pleased that the inquest has found neglect contributed towards his death, the family are intent on getting some semblance of justice for Wayne’s death and will do so in the civil courts.”

Wayne became the unofficial spokesperson of the homeless in Chester after he led a series of ‘protest squats’ in empty commercial premises in 2019, alleging inadequate support and accommodation by the council.