Blaithin Grianne Buckley · Prevention of Future Deaths report

On 11 September 2019 I commenced an investigation into the death of Blaithin Grianne Buckley, aged 26. The investigation concluded at the end of the inquest on 13 September 2019. The conclusion of the inquest was that her death was a Misadventure and that the medical cause of death was:

1a. Hypoxic brain injury
1b. Out of hospital cardiac arrest
1c. Hanging
2. Emotionally Unstable Personality Disorder

The jury found that the death had been contributed to by a breach of procedure at St Andrews in failing to lock the phone booth; an inadequate level of patient history transferred from Wootton Lawn to St Andrews (in particular the previous history of ligature by phone cord); an insufficient process for calling the ambulance service following the incident.

Ms Buckley died on 30 April 2018 at Northampton General Hospital following being found hanging in a phone booth on the Bayley Ward at St. Andrews Healthcare on 26 April 2018 at 23:20, whilst on 5 minute observations. Contrary to the Trust policy, the phone booth door had been left unlocked.

The Trust medical emergency team was alerted to the incident through ascom at 23:23. CPR and life support commenced to good effect. Upon being found Ms Buckley had been conscious. She then fell unconscious with fixed and dilated pupils. The experienced medical emergency team returned a pulse and right heart beat whilst awaiting arrival of an ambulance. The first ambulance arrived at 00:02, having been called at 23:44. Ms Buckley was transferred to Northampton General Hospital at 00:42 in a comatose condition. Brain stem testing on 30 April 2018 recognised that life was extinct.

The critical care consultant at Northampton General Hospital gave evidence that he suspected that an earlier arrival at hospital would not have altered the outcome as 5 minutes was sufficient to establish permanent brain damage.

(1) The delay in calling for an ambulance to transfer Ms Buckley to the General Hospital in a clear medical emergency.

There was no evidence before inquest to explain the delay between 23:20 and 23:44. Whilst it had been accepted that senior clinicians, with greater medical knowledge that the paramedics, formed the medical emergency team, St Andrews as a mental health setting was required to transfer Ms Buckley to A&E in any event.

It was unclear whether the policies/procedures requiring the mobilisation of the medical emergency team included guidance on whether an ambulance should be called, and when.