Female mental health patient dies of postural asphyxia contributed to by hospital’s neglect

Monday 29 March 2010

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An inquest into the death of Ingea Suzanne Brindley culminated on 26 March 2010 with HM Coroner for Derbyshire, Dr. Robert Hunter, returning a narrative verdict recording that Suzanne's death was caused by postural asphyxia, airway obstruction and acute alcohol intoxication contributed to by the neglect of a mental health hospital in Derby. HM Coroner expressed his intention to write two letters pursuant to rule 43 of the Coroners Rules to the Nursing Midwifery Council regarding the training of mental health nurses and the Secretary of State for Health regarding medically trained staff in mental health units.

Suzannes mother was represented by Kirsten Heaven of garden court chambers and Claire Liptrot of Nelsons solicitors.

The narrative verdict: "Ingea Suzanne Brindley died at 19.25 hours on the 3rd of April 2007 on ward 35 of the psychiatric unit which is within the grounds of the Derby City General Hospital. At the time of her death she was a detained patient under section 3 of the Mental Health Act 1983. ON the 3rd April 2007 at a multidisciplinary team meeting her level of observation was changed to general observations which meant she could go of the ward but not leave the hospital grounds. Staff were concerned that should she leave the hospital grounds she would consume alcohol. The medical noted contained a care plan which addressed what action should be taken in respect of her psychiatric condition should she return intoxicated, however there was no plan describing what action should be taken in relation to her physical health needs in respect of her intoxication. Miss Brindley left the ward around 12 noon on the 3rd April 2007 and returned at 13.35 intoxicated to the extent that she had significant motor and cognitive impairment. She has consumed in that time an almost full bottle of rum. She was managed on one to one observations until 16.30 hours when she fell asleep on her bed ad the observations were reduced to checks every 15 minutes. These checks were performed and it was observed that on each occasion she was noted to be snoring loudly and that she had no changed her position. At 18.65 hours she was noted to be breathing differently and that the quality of her snoring had changed. The nurse left her unattended to seek a further opinion. Three members of staff returned and she was found not to be snoring and was pulseless. Basic life support was commenced, however there was a delay in activating the units emergency system and a further delay in contacting the emergency ambulance service.

There was a failure to have a written care plan to address her physical condition from intoxication, there was poor verbal communication between staff with regards to expectations as to how she should be managed. Staff relief on assumptions that other staff members would take action. There was a failure to ensure that Miss Brindley would be seen by a doctor and although two doctors were notified of her condition they failed to make sufficient enquiry into her condition and did not assess Miss Brindley. There was a failure to perform physical observations on Miss Brindley which, had they been done would have alerted staff at an earlier opportunity to her condition. Staff failed to appreciate that the decision to place her on 15 minute observations at a time when she was most at risk rendered her more vulnerable. There was a failure to appreciate the significance or snoring in relation to a partially obstructed airway and a failure to maintain a patent airway. There was a failure to initiate basic medical attention as soon as a breathing problem was identified. Had these failure or omission or any combination of such been addressed before the terminal event of cardiac arrest then on the balance of probabilities Miss Brindley's death would have been avoided.

I therefore conclude that Ingea Suzanne Brindley's death was a preventable death which was contributed to by neglect.


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