A coroner has said there several ‘missed opportunities’ that could have helped save a woman’s life at a mental health unit.
Assistant coroner for Nottingham, Dr Elizabeth Didcock, raised concerns about the care Jayne Jowett received at Annesley House in Annesley - a unit for women held under the mental health act.
The 30-year-old collapsed and stopped breathing at the unit on 23rd September last year, and was pronounced dead hours later after arriving at King’s Mill Hospital.
A post mortem found that she had died from a blood clot on her lungs.
In the days leading up to her death, she collapsed several times and her vital signs scores, such as respiratory rate and oxygen levels, meant she should have been admitted to hospital, but wasn’t.
Such was Dr Didcock’s concerns that she said she would issue a prevention of future deaths report to ensure other patients would not be at risk.
Recording a narrative verdict, she said: “Overall it was clear from the records and charts that there was little understanding of the seriousness of the signs.
“There were clear missed opportunities. It should have led to a hospital assessment.”
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.
It was heard how she had initially settled in well, but became distressed and began hearing voices and had bouts of dizziness and breathlessness.
Following the verdict, Partnerships in Care say they have already taken steps to improve staff training, procedures for the assessment of patients and greater communication between staff and primary care professionals.