FAILURE TO PERFORM OBSERVATIONS LEADS TO PATIENT’S DEATH
News article published on: 13th November 2019
I recently acted in a claim against West London NHS Trust for damages under the Law Reform (Miscellaneous Provisions) Act 1934 and the Fatal Accidents Act 1976.
My client’s mother (BR) died by suicide and there had been failings in her care. He has agreed to me sharing his mother’s story to highlight difficulties faced by people with mental heath issues.
BR, born in Poland, was a UK resident for over 20 years. She visited her GP during that time about various mental health issues and had been under the care of the Ealing Crisis Assessment and Treatment Team since June 2016. She had been admitted to A&E with increased suicidal thoughts on 7 occasions between June 2016 and June 2017.
BR was admitted to Ealing A&E department by ambulance due to an increase in her suicidal thoughts. BR was then admitted to Clay Brook Mental Health Unit at Charing Cross Hospital, at the end of June 2017. She suffered from increased suicidal thoughts, recurrent depressive disorder and hallucinations, among other symptoms.
A clinician attempted to assess BR however, due to the language barrier, it was decided that a full assessment should be postponed until a few days later when an interpreter would be able to attend. In the meantime, BR was placed on 15 minute observations.
That evening, observations took place at 15 minute intervals up until around 01:45. BR was found to be missing from her bed when she was next checked up on by a nurse, at or about 02:10. The nurse on duty proceeded to look for BR in the communal areas.
BR’s body was found against the bathroom door by a nurse. She had hung herself with the use of a ligature. The nurse activated the alarm and attempted to resuscitate BR. There was a further delay in the arrival of the medical team and following their arrival at the scene BR was later pronounced dead.
The inquest hearing took place on 3 July 2018 at West London Coroner’s Court. The Coroner’s verdict was that BR’s death was caused by suicide.
I was instructed to represent BR’s son as the Personal Representative of her Estate. A Letter of Claim was sent to the Trust outlining our allegations of negligence. The Trust denied liability in full for BR’s death, however I then obtained a report from a Forensic Pathologist, who was critical of the care BR received and concluded that she would have had a better chance of survival if she was discovered earlier, and resuscitation was attempted, at an earlier time.
The report was disclosed to the Trust on a without prejudice basis, and after a period of negotiation damages were awarded in the sum of £7,800 (the full value of the claim). I was assisted throughout this case by my Polish speaking colleagues at Osbornes Law and ultimately we were able to achieve a successful settlement for this client.
Blog by Nicholas Leahy.