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Investigation and inquest
On 7th May 2021 I commenced an investigation into the death of Delina Etienne, age 76 years. The investigation concluded at the end of the inquest on 7th & 8th September 2022. I made a determination of a short form conclusion of death from natural causes. The medical cause of death was determined following a post-mortem examination:
1a Ischaemic Heart Disease
1b Coronary Artery Atherosclerosis
Circumstances of the death
Mrs Etienne had suffered from schizo-affective disorder since the mid 1980s and had been treated in the community and in hospital with psychotropic medications to manage her symptoms.
In late 2020 Mrs Etienne suffered a relapse of psychosis and was voluntarily admitted to a mental health ward for treatment. After a period of stabilisation Mrs Etienne was discharged home but returned shortly thereafter when symptoms returned in April 2021. Happily, she seemed to respond to treatment and plans were made for discharge on 8th May 2021.
At 06.00 hrs on the morning of 7th May 2021 Mrs Etienne was observed to be asleep in her bed. At 06.24 hrs when a set of clinical observations were to be taken from the patient, Mrs Etienne was found to be unresponsive by the senior staff nurse on duty. The nurse shouted for assistance but did not follow the expected policy for these circumstances, he did not commence proper checks of the patient or initiate CPR.
Another nurse on duty did commence chest compressions whilst the senior staff nurse went to collect emergency equipment. The senior nurse returned with the emergency bag but critically did not extract equipment from the bag or initiate the use of a defibrillator.
The senior nurse left the scene a second time to establish whether Mrs Etienne was subject to a do not attempt resuscitation order (DNACPR). Such orders are stored in a red folder placed prominently in the ward nurse’s station. The senior nurse ignore that file and instead opened the patient’s electronic medical records and arrived at the erroneous view that Mrs Etienne had a DNACPR in place. He returned to Mrs Etienne’s room and advised his colleague to stop resuscitation. Mrs Etienne was declared deceased at the scene.
The actions of the senior nurse were not found to have caused or contributed to Mrs Etienne’s death, based on relevant expert opinion.
Coroner’s concerns
1. The response of the nursing team to a cardiac arrest was chaotic, and failed to follow trust and national guidelines designed to maximise the effectiveness of resuscitation.
2. Whilst Mrs Etienne was an inpatient, the ward failed to escalate episodes of raised blood pressure for medical review in contravention of trust policy.
3. At no time during the two periods of Mrs Etienne’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.
4. An episode of chest pain identified by nursing staff on 21st April 2021 was escalated for medical review, no evidence of such a review exists.
5. When nursing staff discovered that they had fallen into error by asserting that Mrs Etienne had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted;
A. To officers of the Metropolitan Police who investigated the circumstances of the death that morning,
B. To the Trust’s governance team – an incident report (DATIX) failed to mention the error,
C. To Mrs Etienne’s family who, subject to the Trust’s statutory “Duty of Candour” were communicated with by telephone and in person on 7th May 2021 and in written correspondence on 10th May 2021
Information checked against the published report and official responses