Open and honest investigation when medical care fails. Prompt action when concerns raised. Patients treated with respect at all times. Consistent approach to medical care. Medical staff made accountable for failings.

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 To prevent further failings that has led to serious harm or death of many patients over the past number of years. It might be you, your parents, mate or your child that needs medical care next.


I promised my son I would make them listen. My regret is that, correct treatment never came to save my sons life.

          I will keep my promise to MARK to make them listen.

Mark was refused vital monitoring of a rare condition (arteriovenous malformation) diagnosed at Walsall Manor Hospital. There were ample opportunities to investigate but time and time again he was refused. He was admitted to Walsall Manor Hospital countless times during his final two years, discharged and ignored. Marks Consultant Neurologist Dr Francis(since retired) failed to make notes or highlight concerns raised in most of Marks appointments with him. There was no care plan for emergency admissions, although Marks condition was rare and therefore vital information needed to be available to meet his specific needs. A practice that had been highlighted by the Care Quality Commission (Regulation 20(1)(a)) as an

                    'essential standards of quality and safety'.


We found that 17 of the 18 care records we looked at did not contain appropriate

information and documents in relation to the care and treatment provided. This meant

that people may have been at risk of receiving inappropriate care and treatment arising

from a lack of proper information about them.

We saw that the majority of people's care records we looked at did not include care plans when a need for care was identified. Page 20)


We saw that there were some inconsistencies in the completion and availability of care records in different wards and departments. We noted minor omissions such as no date recorded in several care records we looked at. We also found shortfalls for the records for a person with a learning disability. We asked the Director of Nursing to explore this person's records further. This meant that further improvement was needed to ensure that the risk of people receiving inappropriate care was minimised. For two people whose care records we looked at their falls risk assessments had not been accurately completed.) page 6


Dr Francis continued the same practice of failing to highlight Mark condition in 2013 although he had by now suffered a bleed on the brain. He admits he had a duty of care to Mark but denies any knowledge of his deterioration, although I have evidence he received my e mail in 2011 expressing serious concern for Marks welfare.

 Dr Francis also denies the epilepsy nurse, Avril Morgan (since retired) notified him of any concerns during their weekly meetings, although she repeatedly increased his medication and was aware of the level of concern we expressed to the point she made an home visit.

I questioned if there was a lack of communication between Dr Francis, as head of department, and Avril Morgan but Dr Francis denied that was the case.

Dr Francis stated Avril Morgan was well qualified to monitor Marks epilepsy as a specialist in that field, but he refused to answer my question as to!

                   WHO SHOULD HAVE BEEN RESPOSILBLE                      

                              FOR MONITORING THE AVM?

to which I have not had a reply, although that question was asked in our recorded meeting to him several times.

After warning us Mark was at risk of brain haemorrhage or stroke, they continued to ignore vital warnings signs.

Mark suffered a bleed on the brain, discovered in January 2013 (we believe Mark had suffered from several small bleeds prior to the discovery due to his change in personality, but no one at Walsall Manor Hospital would listen to us) although he remained in a confused state, he was not scanned for three days. We believe this should have been reported as an NRLS concerns as it could have easily put Mark in danger but it was not reported.

We thought after the bleed, closer monitoring would have followed, but the same ignorant attitude continued.

During a meeting with PALs and the presence of two consultants from Walsall Manor Hospital, it was expressed that Mark felt he 'was not going to survive' to which Mark was offered counselling' by Avril Morgan.

Is that the way you deal with a patient who is telling you he feels that, 

                                 at 24, he thinks he is dying?

After two years of complaining that Walsall Manor Hospital were missing something in Marks care, he suffered another brain haemorrhage, just three days after being discharged from QEHB following another collapse.

   A doctor in the accident and emergency department of Walsall Manor Hospital informed us 'he was terminating life support' against our wishes.

              The hospital owes it Mark to admit their mistakes.