02 March 2024 , 18:26
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A psychiatric patient choked to death on a sandwich in a hospital amidst a series of failings, according to a coroner's report.
The inquest into the death of psychiatric patient Severine Kelly in Wotton Lawn Hospital, Gloucester, resulted in the coroner writing to the trust after jurors highlighted 'failings' and delays in staff and paramedics responding to the emergency on October 1, 2002. The inquest in Gloucester last week heard that once staff realised Ms Kelly was choking they attempted to remove the blockage in her airway and resuscitate her.
But the arrival of another staff member at Wotton Lawn was delayed by a faulty alarm system – and the arrival of specialist emergency responders was delayed by 24 minutes after they initially went to the wrong ward. Ms Kelly, 41, was treated at the scene by a doctor and paramedics but they were unable to save her.
As a result of the jury's comments, Gloucestershire Coroner Roland Wooderson issued a Prevention of Future Deaths report to the Chief Executive of the Gloucestershire Health & Care NHS Foundation Trust. Ms Kelly suffered from schizoaffective disorder and had been detained under the Mental Health Act since 2017. She was transferred to Wotton Lawn Hospital in October 2021 and was being cared for in the hospital's Greyfriars Psychiatric Intensive Care Unit.
The jury at the inquest highlighted failings which were admitted by the hospital trust investigator and other witnesses during the hearing. The jurors went on to record a narrative conclusion. The failings revealed during the inquest included, staff should have been aware of the need to update risk assessments and take appropriate action following a medical event that could cause harm to a patient. Specifically, Ms Kelly had suffered a similar choking incident in 2021 which was described by a senior medical professional at the inquest as a "missed opportunity".
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A paramedic attending Wotton Lawn hospital was unsure which ward he should attend due to lack of guidance from staff at the hospital, leading to a delay and the alarm system at the time of her death did not immediately direct medical staff to her bedroom. The coroner said that his report to the Trust chief executive outlined that the medical training of some "bank" (temporary) staff, at the hospital on that day was not up to date.
The report said that a doctor attempting to assist Ms Kelly and speak to the 999-emergency service had to leave her to use a mobile phone due to a poor signal. He did not have access to a portable landline telephone which would have meant that he could have stayed with Ms Kelly. There seemed to be uncertainty at which stage of a medical emergency a medical professional should call the ambulance service and a defibrillator used on that day appeared to not have a working internal clock.
Representatives of the Trust have until April 18 this year to respond to the coroner's report. Ms Kelly's family were represented at the inquest by solicitor Yvonne Kestler from Leigh Day and counsel Sophie Beesley of Old Square Chambers and were supported by the charity INQUEST.
Ms Kelly's sister, Alison Kelly, said: "When Severine passed away I lost my much loved, intelligent and artistic sister. For her to die at the hospital responsible for her care from something as simple as eating a sandwich has been incredibly hard for us to comprehend. During the inquest we have heard about a series of failings during the incident in which she died. However, we were pleased to hear hospital staff who gave evidence being open and honest about these failings."
Severine's mother Mrs Kelly said: "My beautiful, talented daughter lost her life at the hospital which was entrusted with her care. Sadly, our grief has been compounded by hearing about failures during the attempts to save her life. Nothing can ever make up for the loss we feel as a family and we sincerely hope the hospital takes action to ensure no other family has to endure what we have been through."