Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0087, written 18 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Mar 2022 |
|---|---|
| Reference | 2022-0087 |
| Deceased | Gary Ottway |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Gary OTTWAY (died 01.04.21)
THIS REPORT IS BEING SENT TO:
1.
Chief Executive Officer
East London NHS Foundation Trust
Trust Headquarters
9 Alie Street
London E1 8DE
1 CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2 CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 7 April 2021 I commenced an investigation into the death of Gary
Ottway aged 41 years. The investigation concluded at the end of the
inquest on 11 March 2022. I made a determination at inquest that Gary
Ottway died from natural causes, being two heart conditions.
His medical cause of death was:
1a acute left ventricular failure
1b valvular heart disease with significant cardiomegaly and
coronary artery disease.
4 CIRCUMSTANCES OF THE DEATH
1
Death was triggered by the psychological stress and physical exertion of
a severe mental health episode. Mr Ottway had been admitted to Mile
End Hospital and detained under section 2 of the Mental Health Act, and
at the time of his death was being detained alone in a seclusion room
where he was under constant / continuous nursing observation.
Nevertheless, he was found in cardiac arrest, cold and with post mortem
staining (hypostasis).
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
1. Though Mr Ottway was meant to be under constant nursing
observation, not only was he in cardiac arrest but he was also cold
and exhibiting hypostasis when he was found. This appears to
indicate that either the nursing observation was not constant, or it
was not effective. I appreciate that the trust is putting in place a
new IT system to monitor signs of life, but nevertheless basic
nursing observations must be performed competently.
When the senior duty nurse and the nurse undertaking continuous
observation noted that they could not see evidence of respiration, they
did not immediately enter the seclusion room where Mr Ottway lay,
because they deemed that unsafe following his earlier violent behaviour.
2. The senior duty nurse told me at inquest that he could not be sure
that Mr Ottway was not holding his breath, though he had never
done this and there was no evidence that he was doing so now.
3. The senior duty nurse also told me that the visibility through the
Perspex panel was poor, though he had never brought this to
anyone’s attention and did not do so after Mr Ottway’s death.
4. The senior duty nurse told me that the nurses would not enter the
seclusion room until the rapid response team was present, but he
did not call the rapid response team as soon as he suspected that
Mr Ottway was not breathing. Instead, he started by going to get
one of the other nurses, which took a couple of minutes; then he
rang the duty doctor; and only after that did he radio for the rapid
response team.
2
5. The junior doctor was the last person to attend the resuscitation
and told me he did so after the rapid response team, yet no one
had entered the seclusion room by the time he arrived.
It may be that there was a (perhaps unconscious) reluctance to
enter the room without a doctor, despite the presence of the rapid
response (nursing) team. But by the time the junior doctor got to
the door and immediately identified that Mr Ottway was not
breathing, at least six and a half to seven minutes had elapsed
since the first two nurses saw no evidence of respiration. This
was well outside the three to four minute window of opportunity
for resuscitation without inevitable brain damage or death.
6. In the six and a half to seven minutes before the junior doctor
arrived at the seclusion room, the emergency grab bag had not.
That took another 30 seconds, though to retrieve it was only a
three minute round trip from the room where the nurses who had
first identified the lack of respiration were waiting.
7. The junior (and only) doctor called to assist in the attempted
resuscitation was not familiar with the contents of the emergency
grab bag, told me that it would not have occurred to him to ask for
any equipment to assist with ventilations other than a pocket
mask, and explained that he was not trained in giving adrenaline
or any other medicines for resuscitation.
As he was the only medical resource available in the case of an
emergency, these seem significant gaps.
8. When paramedics arrived, they found that chest compressions
were being given (by nursing staff) to Mr Ottway’s abdomen
instead of his chest, thus rendering them ineffective.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 16 May 2022. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise, you must explain
why no action is proposed.
3
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
•
• Care Quality Commission for England
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, Gary Ottway’s father and sister
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
9
DATE SIGNED BY SENIOR CORONER
18.03.22 ME Hassell
4
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