Coroner orders Edgware Community Hospital to take action following the death of 35-year-old Barnet musician

Senior Coroner Andrew Walker has given Edgware Community Hospital until 1 November to outline how it will prevent future deaths following the inquest into the death of 35-year-old Barnet musician, Benjamin (Ben) Brown. The inquest into Mr Brown’s death heard that hospital staff failed to carry out the appropriate level of checks on the night he died, and falsified records.

The Trust has until 1 November 2016 to show what action is being taken to address the coroner’s concerns.

Ben Brown, who had studied music at the highly-regarded Leeds College of Music and had been a volunteer at the hospital, was a patient on Avon Ward at the Dennis Scott Unit at Edgware Community Psychiatric Hospital, part of Barnet, Enfield and Haringey Trust, when he died on 25 July 2015.

During the early hours of 18 July, he was voluntarily admitted to Thames Ward at Edgware Community Hospital, and transferred to the Psychiatric Intensive Care Unit (Avon Ward) on 19 July, after being sectioned under Section 2 of the Mental Health Act.

Ben was given Clozapine, an antipsychotic medication, and his dosage was later increased. There were supposed to be 15-minute intermittent observations and hourly checks carried out by ward staff. However, an agency Registered Mental Health Nurse, was not told about the need for 15-minute observations, and having taken hourly observations told the inquest that he was pressured into making entries in the observation records for times when Ben was not observed.

A “Serious Root Cause Analysis Investigation Report” conducted by the Trust found that CCTV footage showed “significant omissions of care” in relation to Ben. Specifically, the report found that between 1:19am and 5.37am, 15 minute checks were not carried out. With regard to hourly checks, these were not carried out at 2:09am, 3:03am and 4:01am.

It also emerged during evidence at the inquest that the last observation on Ben recorded as having taken place at 8.30am – Ben being noted as in bed, asleep – did not take place because the healthcare assistant due to undertake these observations had been sent to another ward to get bread for all the patients’ breakfast. At the inquest, the healthcare assistant described how he panicked when the alarm went off and wrote in the observation at this time.

At 8:51am on 25 July, a staff nurse entered Ben’s room to find that he was blue, not breathing and with no pulse. He had suffered a cardiac arrest.

The Trust’s report found that the response to Ben’s cardiac arrest was inadequate and highlighted:

• A duty doctor was not bleeped and alerted to the emergency. The duty doctor only attended by coincidence when attending the ward for another reason approximately 17 minutes after Ben had been found;
• The emergency medical bag was not properly stocked with resuscitation equipment;
• Oxygen was not administered prior to the duty doctor’s arrival, resuscitation cycles were not being counted and timed; and that sometimes staff were stopping chest compression even when instructed to continue;
• The Trust’s training records showed that none of the staff on duty at the time of Ben’s death had attended and completed Immediate Life Support Training which is mandatory for all inpatient staff, and only two members of staff on the shift had basic life support training.

It is understood that at least one member of staff is facing disciplinary proceedings but the Trust has to date refused to provide any further details to Ben’s family.

Clair Hilder, a civil liberties solicitor and senior associate at London law firm, Hodge Jones & Allen represented Ben’s mother, Elizabeth Brown, at the inquest. Clair says: “This is a very sad case of health professionals failing to consider the needs of a mentally-ill patient and then trying to cover-up their mistakes.

“This case highlights a disturbing trend that I have seen in a number of cases where observations which are supposed to be made to safeguard patients are not taking place. These failings would never have come to light if it weren’t for CCTV. However, CCTV needs to be there to check that the correct observation procedures are routinely being made, not just as a tool to confirm what went wrong when it’s too late.

“I find it beyond comprehension that Trust management allowed the ward to run without staff having had mandatory life support training.”

Following the inquest, Trust submissions revealed requisite Immediate Life Support Training had still not been undertaken by 100% of those who work on the ward.

On 10 March 2016, Senior Coroner Andrew Walker at Barnet Coroner’s Court concluded Ben died of natural causes. He found that the time Ben suffered a cardiac arrest is likely to have been between 5am and 8:45am and that the cardiac arrest was identified outside the time window for successful resuscitation.

Ben’s mother, Elizabeth Brown, is in the process of submitting a written complaint to the Trust’s Chief Executive. Ms Brown says: “I speak on behalf of all Ben’s family in expressing the deep heartache of losing him in such traumatic circumstances and how appalled we were at the failures in Ben’s treatment and care on Avon Ward.

“Even though my son had previous hospital admissions, he had been well for seven years and so his death came as a dreadful shock. Ben gave his time generously to the hospital in the past, having played saxophone on the wards and volunteered in the coffee shop, yet when he turned to the hospital in a crisis I feel he was let down.

“The inquest process has been very hard as it doesn’t treat your loved one as a person and I don’t want my son to be another faceless statistic. I will remember Ben as a gentle, caring and intelligent man who easily made friends. He was a talented musician who loved jazz, playing in Big Bands and supporting Arsenal. He was also courageous and passionate about de-stigmatising mental illness and I will always be proud of him. I won’t rest until I get answers from the Trust about aspects of Ben’s care not dealt with at the inquest or in the hospital investigation, such as the delay in getting him admitted to hospital in the first place.”

In a Prevention of Future Deaths Report sent to the hospital last month, Mr Walker said:

“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:

• The auditing of those persons carrying out 15 minute observations.
• Training of staff for resuscitation in the event that a patient collapses.
• The auditing for the prescription and management of clozapine.

Counsel representing Ben’s family at the inquest was Tom Stoate of Garden Court Chambers, and Tim Baldwin, also of Garden Court Chambers, represented the family at the pre-inquest review hearings.

For further information, please contact:
Kerry Jack or Louise Eckersley at Black Letter Communications
kerry.jack@blacklettercommunications.co.uk or louise.eckersley@blacklettercommunications.co.uk