Doctor’s inadequate observation did not lead to death of Campbell Centre inpatient

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THE inquest into the death of Helen Wills 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 in the moments after she stopped breathing, shortly 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 whilst 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 yesterday, heard evidence from nurses, doctors and the police, who had held their own investigations into the death which was medically ruled to be due to sudden adult death syndrome.

Miss Wills, 45, was found dead in a seclusion room shortly before 7am on May 22. She had been placed there after trying to break through a fire door.

Around 10pm on the evening before her death she had entered the Campbell Centre’s medical room asking for an injection for pain relief to a sore ankle.

She was refused and one nursing assistant, Neil Dallison, told the inquest how she had become aggressive before falling asleep on the floor of the nurses’ room.

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 by staff and when she failed to settle into a seclusion room where she fell asleep on her back and was described by a number of witnesses as ‘snoring loudly.’

The inquest had earlier heard evidence from Detective Sergeant Neil Robinson, who said he was satisfied no suspicious circumstances surrounded the death.

The post mortem, carried out on May 29 by Home Office pathologist Dr Nicholas Hunt, found no sign of injury to the face neck and head of Miss Wills and found no restraints had been used on her ankles or wrists.

The jury agreed with the three risk factors for Helen to have died from Sudden Adult Death Syndrome – these didn’t relate to vital signs, but were 1) she was schizophrenic 2) she was on anti-psychotic drugs; and 3) her behaviour was chaotic. The inquest also heard lack of sleep would have been a fourth risk factor, hence why the clinical decision was made to allow Helen to continue sleeping.

Verdict: Narrative. The cause of death was sudden adult death syndrome, with a slight cardiomegaly (slightly enlarged heart), in a patient with schizophrenia.