Jayne Jowett · Prevention of Future Deaths report

On the 29th October 2014, I commenced an investigation into the death of Jayne Jowett, aged 30 years. The investigation concluded at the end of the inquest on 27th March 2015. The conclusion of the inquest was a Narrative as follows: On the 15th September 2014 Ms Jayne Jowett became unwell. She had intermittent but continuing respiratory difficulties, with low oxygen saturations at times in the days prior to her death. She was not taken to hospital for assessment. She died of a pulmonary embolus on the 23rd September 2014.

Ms Jowett was resident at Annesley House, a Partnerships in Care facility, providing low secure and locked rehabilitation mental health care for women. She was detained under section 47/49 of the Mental Health Act 1983. She had a learning disability and a personality disorder. She was on a range of psychotropic medication, and had asthma. She was smoker.
From the 15th September 2014 she was unwell with intermittent symptoms of dizziness, breathlessness and episodes of collapse, needing oxygen. She was seen by the doctors and nurses at Annesley House, and by her GP. Her vital signs were monitored using the National Early Warning Score (NEWS) system. Guidelines as to how to respond to rising NEWS were not followed, and no hospital assessment was organised. There were missed opportunities by both Partnerships in Care and by the GP to recognise and respond to her clinical condition in the days prior to her death

Following the Hearing I received an additional statement and documents from Partnerships in Care addressing issues that arose during evidence. These documents went some way to addressing concerns raised, however, in my view there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed.

1. PIC Staff Training in National Early Warning Scores: Training in both interpretation of scores, and response to escalation in scores has not to date demonstrated improvement in assessment of a patients clinical condition. The impact of training on patient assessment requires ongoing audit and monitoring.

2. PIC staff at Annesley House have low levels of understanding of the significance of clinical signs such as cyanosis, pallor, breathlessness, and the significance of a patient needing oxygen treatment. There are no plans currently in place to address this

3. There remains no clear current service level agreement regarding how best for PIC to work with the local GP surgery to provide high quality joint care. There is no clear guidance that ensures all information regarding a patient’s physical condition is communicated to a GP when seeing a patient.