Woman, 25, with Asperger's dies following multiple failures at Milton Keynes mental healthcare unit, court hears

Sian Hewitt died of a blocked lung vessel on April 6 2019 at Milton Keynes University Hospital where she was taken after collapsing on Willow Ward at the Campbell Centre.

On admission to the Campbell Centre on March 13 and during the period of her admission in 2019, there were multiple failures in treatment, the court heard.

Senior Coroner Tom Osborne said in a report: "There was a failure to recognise how seriously ill she had become and this resulted in lost opportunities to treat her appropriately that may have prevented her death.

"There was a failure to appropriately treat her to control her mania and a failure to assess, recognise or treat the risks of her developing a pulmonary embolism and these failures may have caused or contributed to her death."

The court also heard that there were multiple opportunities to realise that Ms Hewitt had become unwell on April 6 2019 that were missed and which led to a failure to start effective CPR.

The coroner has also questioned whether the Campbell Centre was the right place for Ms Hewitt to be sent to and has called on NHS England for a response.

Mr Osborne said: "It would appear from the circumstances of Ms Hewitt‘s death that the NHS are unable to provide a place of safety for those who are suffering from Asperger’s syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar.

"The Campbell Centre in Milton Keynes was not an appropriate placement and I believe this matter should be looked at by NHS England and for more appropriate provision to be made for such patients."

The coroner said he believes action should be taken by NHS England to prevent deaths similar to this from happening in the future.

A spokesperson from Central and North West London NHS Trust, which runs the Campbell Centre, said: "We accept the coroner’s report and have apologised to the family for the failings in our care provision.

“Since Miss Hewitt’s death, the team at the Campbell Centre have made a lot of changes to how care is delivered for patients with complex mental and physical health conditions.

“The clinical staff have undergone extensive education and training on how to recognise the physically deteriorating patient. Now over 95 per cent of patients are assessed for their VTE (blood clot) risks on admission (some refuse and are assessed after admission).

"We have improved the medical cover arrangements and escalation procedures within the service to improve responsiveness and the quality of care delivered.”