Coroner’s ‘serious concerns’ after death in Annesley mental health unit

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A coroner has raised ‘serious concerns’ over the healthcare provided to a patient at a mental health unit in the days leading up to her sudden death.

Jayne Jowett (30) collapsed and stopped breathing while she was a resident at Annesley House, a secure unit in Annesley for women detained under the mental health act.

Miss Jowett, who had a history of self harm and heard voices telling her to kill herself, died from a blood clot in her chest on 23rd September last year, a post mortem found.

But the care she received in the days before her death was brought into question during an inquest at Nottinghamshire Cororners’ Court.

During evidence from Dr Nasser Abdelmawla, consultant psychiatrist at Annesley House, the inquest was told how registered a ‘nine’ on the early warning scoring systems of vital signs three days before her death, meaning she should have received emergency medical assistance, but didn’t.

The observation checks look at temperature, pulse rate, respiratory rate and oxygen saturation levels in the blood.

Assistant coroner for Nottingham Dr Elizabeth Didcock told Dr Abdelmawla: “I’m struggling to understand why there was no emergency response that morning.

“If you have a score as high as that,I hope there would be an appropriate response.”

She asked why an ambulance was not called, with Dr Abdelmawla saying that from the notes made it seemed that there were improvements to her vital signs after that and there was ‘no need to call the emergency services’.

Putting questions to Dr Abdelmawla, Miss Jowett’s sister, Karren-Anne Gowdridge fought back tears as she said: “I’m not a doctor but it’s clear from what I’ve heard she should have been taken (to hospital) rather than leaving it three days. It could have been the difference between us sitting here today and not (sitting here).

The inquest was told how mother-of-one Miss Jowett had been admitted to Annesley House, a 28-bed unit, in June of last year.

She suffered from epilepsy, asthma, was ‘significantly’ overweight and had an emotional unstable personality disorder with bouts of depression.

She had been moved from another secure unit in Norfolk, which, like Annesley House, is also run by Partnerships in Care - an independent provider of secure care.

It was heard how she had initially settled in well at Annesley House, but became distressed and began hearing voices.

She was then prescribed the anti-psychotic drug, clozapine, and despite the risks of severe side-effects, began to make progress, according to Dr Abdelmawla.

However, she then had bouts of dizziness and breathlessness.

On the day of her death, a doctor was called who said she needed to go to hospital because she was ‘gasping for breath’.

She was able to leave her room but collapsed before leaving the building. She was able to get to her feet, but collapsed again and stopped breathing.

Staff tried and failed to resuscitate her, as did ambulance paramedics and then staff at King’s Mill Hospital, before they declared her dead.

Dr Didcock adjourned the inquest for written submissions to be provided by Partnerships in Care about staff training and their understanding of the early warning scoring system.

She said: “I’m concerned that you are unable to reassure me of these matters. I have to ask if this could happen again tomorrow, and I think it’s possible.”

A verdict will be returned on 27th March.