Margaret Elizabeth Conway · Prevention of Future Deaths report

On 12th September 2016 I commenced an investigation into the death of Margaret Elizabeth Conway, aged 68. The investigation concluded at the end of the Inquest on 24th March 2017. The conclusion of the Inquest was Natural Causes, the cause of death being:-

1(a) Acute Myocardial Infarction
1 Acute Severe Colitis

I also recorded that “Margaret Elizabeth Conway suffered with mental health issues mainly attributed an obsessive compulsive disorder. She had been admitted to Fieldhead Hospital where she became unwell with gastrointestinal problems ultimately diagnosed as colitis. Her care was transferred to Pinderfields Hospital, Wakefield, where her death was confirmed at 0110 hours on 3rd September 2016.

Margaret Elizabeth Conway was a widowed lady aged 68 and was a retired Hospital Clerk who was the subject of Section 3 of the Mental Health Act. Mrs Conway was admitted to Pinderfields Hospital, Wakefield from Fieldhead Hospital, Wakefield, a psychiatric hospital, on 24th August 2016 with a one week history of diarrhoea and acute kidney injury. A CT scan showed that she had pancolitis. She had a sigmoidoscopy which showed an acute colitis but the cultures for which were all negative. She was given intravenous steroids on Friday 2nd September 2016. Mrs Conway suffered a cardiac arrest requiring multiple cycles of CPR. Despite all efforts her death was confirmed at 0110 hours on 3rd September 2016.

With the assistance of Professor Stephen Curran, Consultant in Old Age Psychiatry and Clinical Lead who is based at Fieldhead Hospital and who was involved in Mrs Conway’s care, I wish to address the issue of patients experience in mental health issues and who are in-patients at Fieldhead Hospital but who have or developed physical health problems acutely which require treatment.

(1) The Acute Medical Wards Mental Health Services are geographically and operationally separate.
(2) Transfers of patients who are experiencing both serious mental and physical health problems can sometimes be very challenging.
(3) PLT Services are now more actively involved in patients transferring to the Acute Wards.
(4) Closer working such as joint ward rounds and NDT working should be explored as well as the development of a clear pathway/flowchart to facilitate closer working and in the longer-term the development and use of a shared resource with a small number of jointly funded and managed beds. Such measures would improve the care of patients with both severe physical and mental illness and also reduce the need for multiple transfers between the two organisations.