The brother and sister of Michelle Jannetta, who died at Milton Keynes Hospital, have described her as fun-loving and caring in a touching tribute.
The inquest into the 31-year-old’s death, which concluded on Monday, found she had died after hospital staff failed to make correct observations after she had taken an overdose of pain relief pills, Tramadol.
Coroner Tom Osborne issued a Rule 43 ruling to the Hospital Trust and Secretary of State, Theresa May MP, which allows each just 56 days to make a written response addressing what measures need be put in place to prevent similar failings in the future.
The inquest, held at Milton Keynes Coroner’s Court on Thursday and Friday, heard Ms Jannetta, of Dorchester Avenue, Bletchley, who had previously claimed to have taken overdoses, was admitted to hospital at 5pm on March 7 last year.
After showing no signs of taking an overdose and initially refusing to tell nurses that she’d taken anything the hospital offered to release her.
Ms Jannetta then claimed to have taken an overdose of Tramadol and the hospital kept her in overnight for observation, with a police guard to prevent her from leaving – something she had done in the past.
At around 3am nurses heard Ms Jannetta snoring – a known symptom of a Tramadol overdose. With her oxygen saturation at 88 to 89 per cent nurses rolled her on to her side to sleep, instantly improving her saturation levels and stopping the snoring.
Her saturation levels were taken by a nurse and written on a surgical glove, but were not included in the observation notes.
She was left on a monitor with her cubicle door open for nurses to keep an eye on her.
Later during the night police observed she continued to snore and appeared semi-conscious, following instructions to sleep her on her side. Shortly after 11am doctors were unable to wake her.
The narrative verdict stated: “There was a failure to undertake and report on her regular observations and a failure to recognise her deteriorating condition or the seriousness of her situation that resulted in a lost opportunity to render further effective treatment before she went into respiratory arrest caused by obstruction of her airway. Attempts at resuscitation were unsuccessful and she died at 11.18am on March 8, 2012.”
Michelle’s sister, Nicola Rose, said: “Michelle may have suffered with mental health issues but to the family she was a fun-loving and caring person who was very much adored by every one of us.
Michelle was a very much loved aunt, daughter and sister who we all miss desperately. It has been incredibly difficult to come to terms with her untimely death.
“We wish she was still here bringing smiles to us all and we’ll never forget her. We can only hope that her tragic death will bring a change to attitudes towards mental health patients who are being treated in a general hospital and make it a safer place for the vulnerable and those struggling with mental illness.”