Inquest rules hospital failed to make correct observations on patient who died of an overdose

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A city coroner is to write to the Secretary of State for Health for answers as to why a healthcare assistant was left to take vital observations of a patient who died at Milton Keynes Hospital.

Tom Osborne today recorded a narrative verdict into the death of Michelle Paula Jannetta, who died on March 8, 2012, after taking an overdose of pain-relief pills, Tramadol, the day before.

He will be writing to both the Hospital Trust and Secretary of State, Theresa May, with a Rule 43 ruling. This allows each just 56 days for a written response addressing what measures will 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 refusing to tell nurses that she’d taken anything the hospital offered to release her.

Ms Jannetta, of Dorchester Avenue, Bletchley, 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.”

Her brother and sister, Stuart Jannetta and Nicola Rose, issued a short statement after the conclusion of the inquest today.

Nicola said: “She should have been monitored closely. She was a frequent visitor to the hospital and we think they definitely disregarded her visits as if she was an inconvenience to them. I believe they thought she was time-wasting.

“It is a small consolation to us that in reporting the problems she hasn’t died in vain. If it helps people across the country then that is a benefit without a doubt.”