Christopher Brennan · Prevention of Future Deaths report

On 2nd September 2014 I commenced an investigation into the death of Christopher Brennan, age 15. The investigation concluded at the end of the inquest on 21st September 2016. The conclusion of the inquest was that Christopher died from asphyxia due to acute upper airway obstruction. The circumstances in which he came by his death were recorded by the jury in a narrative form, as follows:
Christopher suffered from mental illness and was a patient at Bethlem Adolescent Unit at the Bethlem Royal Hospital, Beckenham. He had a history of hearing voices, suicidal ideas, and self harm, usually by swallowing objects. On 31st August 2014 at about 8 pm, Christopher went to the communal toilet on the unit and obstructed his airway by swallowing the lid of a roll on deodorant wrapped in tissue paper. He called for help but suffered a cardiac arrest before the obstruction could be removed, and could not be resuscitated. Christopher’s actions were in part because of cumulative and continuing failures in risk assessment and management. His death was contributed to by neglect.

Please see the narrative conclusion set out in paragraph 3, above

(1) In respect of the in-patient management: that there was no separate policy or guidance, other than a partial wall chart, regarding the assessment and management of risks posed by items that might be used to cause self harm. The complexities of managing these risks on an adolescent in-patient psychiatric unit were not therefore adequately considered, and this led to a lack of clarity and consistency.

(2) With regard to resuscitation: the emergency equipment on the unit did not include a laryngoscope. The item obstructing Christopher’s airway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope, and this combination had been successfully used on a previous occasion when Christopher had swallowed a bottle top.

Laryngoscopes are not part of the standardised items on the unit, and are not included in the Resuscitation Council guidance for mental healthcare settings. It has been suggested that this is because they are complex devices that require intense training and competency assessments before staff can use them, and that it may be counterproductive to make them available. However, in view of the circumstances of Christopher’s death, and the apparent prevalence of self harm in adolescent units, the matter is reported for consideration, both in relation to the laryngoscope itself and the access to staff trained in its use.