Carole Rita Lovett · Prevention of Future Deaths report

On the 2nd June 2015 I opened an investigation touching the death of Carole Rita Lovett, aged 63 years old. The inquest concluded on the 22nd February 2016. The conclusion of the inquest was “Narrative”, the medical case of death was 1a Bronchopneumonia 1(b) Hypoxic brain injury complicating hypoxic cardiac arrest, 1(c) Clozapine associated myocarditis and Schizophrenia under paragraph 2.

Having become unwell Carole Rita Lovett, a patient under Section 3 of the Mental Health Act 1983 at St Ann’s Hospital, was transferred to Northwick Park Hospital on the 16th May 2016.

Mrs Lovett had developed a myocarditis as a consequence of the use of Clozapine medication.

Mrs Lovett was placed in the Acute Assessment Unit of the hospital where the deterioration of her condition continued until she was found un-responsive in her bed at 14.35 in the early afternoon.

Mrs Lovett was resuscitated and transferred to the Critical Care Unit where she died on the 31st May 2015.

The level of competence and training of staff working in the Acute Assessment Unit with regard to the use of NEW Score system and communication between all levels of staff.

That when the monitoring equipment alarmed this did not result in senior staff attending.

No consideration was given, when the alarms were continuously sounding, for alternate forms of monitoring.