Mansfield mental hospital patient’s death sparked ‘chaotic’ response from staff
An inquest into the death of a patient in a Mansfield mental hospital heard the staff's response to finding him was "chaotic" but the care they provided was “reasonable.”
Alastair Pearson, aged 58, was found on the floor of his room at Sherwood Oaks Hospital just after midnight on March 21 last year.
Karen Boyle, assistant coroner for Nottinghamshire, said a 999 call was made eight minutes later and staff began CPR and gave him a defibrillator shock.
Mark Pepper, a paramedic with East Midlands Ambulance Service, who arrived seven minutes after the call, said: "The scene was very chaotic and no one person took control of the situation even though several medical professionals were present.”
He considered their CPR was “poor” and made a safeguarding referral as he felt the staff could benefit from more training.
Mr Pearson was pronounced dead at the scene and a post-mortem revealed the cause of death was acute cardiac failure due to hypertension, diabetes, and emphysema.
Detective Constable Jonathan Evans interviewed staff and formed the opinion that the chaotic and noisy state of the staff "was due to a desire to help and do their best,” adding: “It would be harsh of me to criticise people for wanting to help.”
Some of the hourly checks staff carried out on Mr Pearson before his death were made through the hatch, he said, adding: “I would imagine if the room was in total darkness it would be difficult to get a good look at someone.”
Louisa Hagen, a registered mental health nurse who reviewed what happened under the Patient Safety Incident Response Framework (PSIRF) said there was "no evidence that the staff response was not effective," describing it as "timely."
The inquest heard Mr Pearson, who was diagnosed with schizophrenia and detained at the hospital under the Mental Health Act, would refuse medication, but there was no evidence in his records of any wider discussions with him to tackle the problem.
Recording a conclusion of death by natural causes on Friday, the coroner said she was satisfied neither the CPR nor the incomplete observations contributed to his death and the care he received was reasonable.
"He was a gentle soul,” Mr Pearson's cousin told the inquest. “He had so much going for him earlier in his life. It all got destroyed by his mental health."
Diane Hull, chief nurse at Nottinghamshire Healthcare, said resuscitation training for staff has been increased and processes for the management of long-term health conditions on their inpatient mental health wards have been reviewed.