John James Leo Scallan · Prevention of Future Deaths report

On the 7th day of June 2016 my Senior Coroner, Sean McGovern, commenced an investigation into the death of John James Leo Scallan. I concluded the investigation by way of a two day inquest on the 1st day of November 2017.

The medical cause of death was 1a Respiratory depression from sedative drugs codeine, morphine and zopiclone.

My Conclusion was a narrative: Mr Scallan was prescribed the drugs found in his body post-mortem but the levels of codeine, morphine and zopiclone exceeded those actually prescribed.

Mr Scallan was admitted to University Hospital Coventry & Warwickshire on the 24th day of May 2016 after sustaining injuries as a result of an alleged assault. During his admission he underwent an operation to fix a fracture of the mandible.

On the 27th May 2016 following an outburst on the ward Mr Scallan left the ward and on his return and on the advice of a Consultant Psychiatrist, he was transferred to the Hearsall Ward at the Caludon Centre on the 28th May 2016 as an informal patient where he was placed on Level 2 – intermittent observations otherwise known as 15 minute observations.

On the 29th May 2016 at 12:25 hours in his bedroom at the Caludon Centre, he was found to be unresponsive following a cardiac arrest.

During his admissions he was prescribed and administered drugs; however, the levels found in his blood after death were in excess to that prescribed.

There was no explanation as to how this occurred. No concerns regarding his condition had been raised by those observing him.

1. 1. The adequacy and reliability of the intermittent observations.

2. 2. The Observation and Engagement Policy indicates checks should be seen in terms of positive engagement with the patient and involve, whenever possible, interaction and positive contact with the patient and sighting the patient from a distance and recording whereabouts is not acceptable intermittent observation.

The evidence from the front-line health care assistants showed little insight into the requirements of intermittent observations as well as awareness of the new observation sheets and how these should be completed in line with the policy.

There was a clear reluctance by members of staff to enter a patient’s room to conduct observations in particular, when the patient was sleeping in the middle of the day.