THE grieving mother of a woman who died at the Campbell Centre has said lessons need to be learned.
Anne Jenkins’ daughter, Helen Wills, died in the early hours of May 22 in a seclusion room at the centre after what was medically concluded to be sudden adult death syndrome.
Mrs Jenkins said: “There are always lessons to learn and always at an innocent person’s expense. Why do we always have to hear this? In my opinion Helen should have been checked more.
“My daughter was a wonderful lady. She was loyal, caring and extremely kind. Most of the time her illness was controlled by her medication and she was able to lead a happy, normal life.
“She lived in her own flat at New Bradwell, she could travel wherever she wanted and she had coped extremely well. Before this episode, it had been 14 years since she had needed to be admitted to a mental health unit for help.”
An inquest into Miss Wills’ death heard on the night of May 21, Helen had complained of ankle pain and after being refused treatment had become aggressive before falling asleep on the treatment room floor.
She was taken back to her room and placed on level 3 observation. However, at 1.30am on May 22 she tried to break through a fire door in her room using a fire extinguisher and was placed into a de-escalation room. When she failed to settle she was moved to a seclusion room with staff checking her every 15 minutes.
Mrs Jenkins added: “It was during one of those 15-minute gaps in isolation that my daughter died.”
After a three-day inquest the coroner returned a narrative verdict and a jury found that a doctor carried out an inadequate observation in the hours before she died.
They also found there was an inadequate procedure to administer oxygen in the moments after she stopped breathing. However, the two factors were not thought to have contributed to her death.
Reading from the narrative verdict, on November 20, 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.”
Anna Selby, Director of Joint Mental Health Services in Milton Keynes, said: “This is a tragic case and Helen’s family have our deepest sympathy.
“Helen died from natural causes and the inquest last month concluded that none of the care provided to her contributed to her death.
“In all cases where an incident has happened, no matter how serious, we investigate what we could do differently to improve the care provided. In this case, measures were identified as part of our own review processes conducted shortly after Helen’s death and have already been implemented.
“Helen had been under our care for many years and her death deeply upset local staff who had cared for her during this period.”