THE inquest into the death of a Campbell Centre patient has found a doctor carried out an inadequate observation in the hours before her death.
An eight-strong jury also found there was an inadequate procedure to administer oxygen after Helen Wills stopped breathing, before 7am on May 22. However, the two factors were not thought to contribute to her death at the Campbell Centre.
Reading from a narrative verdict, the foreman of the jury said: “No vital observations were taken after 1.54am on May 21 at Helen’s request. However, her respiration rate was observed on May 22 at 1.05am and 2.30am. The jury consider the clinical decision not to take vital signs and let her sleep reasonable.
“However, there was an inadequate examination by the doctor who could have taken a pulse manually while Helen was asleep. Nursing staff had a varied understanding of the need for monitoring. There were inadequate procedures to administer oxygen, but the jury do not feel that this was a contributory cause of Helen’s death.”
The three-day inquest, which concluded on Tuesday, heard evidence from nurses, doctors and the police. The death was medically ruled to be due to sudden adult death syndrome.
Miss Wills, 45, was found dead in a seclusion room shortly before 7am. She had been placed there after trying to break through a fire door.
Around 10pm on the evening before she had entered the Campbell Centre’s medical room asking for an injection for pain relief to a sore ankle.
She was refused and nursing assistant, Neil Dallison, told the inquest she had become aggressive before falling asleep on the nurses’ room floor. At 1.30am, after she was placed on level three observation, meaning she had to be checked every 15 minutes, she began barging a fire door before hitting it with a chair and a fire extinguisher.
She was moved into a de-escalation room and then into a seclusion room where she fell asleep on her back and was described as ‘snoring loudly.’
The post mortem, carried out on May 29 by Home Office pathologist Dr Nicholas Hunt, found no sign of injury to Miss Wills’ face, neck and head and found no restraints were used on her ankles or wrists.
The jury agreed with the three risk factors for Helen to have died from Sudden Adult Death Syndrome in that she was schizophrenic, on anti-psychotic drugs and her behaviour was chaotic. The inquest heard lack of sleep would have been a fourth risk factor, hence the clinical decision to let her sleep.
Verdict: Narrative. The cause of death was sudden adult death syndrome, with a slight Cardiomegaly (slightly enlarged heart), in a patient with schizophrenia.