Ratidzai Kudkawashe SANGARE · Prevention of Future Deaths report

On 21st April 2015 I commenced an investigation into the death of Ratidzai Kudkawashe SANGARE, 38. The investigation concluded at the end of the inquest on 17th May 2016. The conclusion of the inquest was that Mrs Sangare died from ligature compression of the neck. The jury recorded a narrative conclusion: that Mrs Sangare died between 5.15 and 8.28a.m. on Millbrook Ward. She was found face down with a dressing gown belt around her neck that caused the ligature compression.

Mrs Sangare was a detained patient with a diagnosis of acute psychotic disorder (in remission) and personality disorder. On the morning of her planned discharge she was found unresponsive on the floor of her room with a dressing gown belt around her neck. Efforts to resuscitate her and to call for medical assistant were delayed, though it is not possible to determine whether the delay contributed to the cause of death.

(1) Healthcare staff were unaware or did not recognise that Mrs Sangare's condition required immediate cardiopulmonary resuscitation, the activation of the alarm, and the summoning of an ambulance
(2) Staff did not respond immediately to alarm when it was activated, on the assumption that it was likely to be a behavioural issue or false alarm rather than a medical emergency
(3) Access to a telephone was limited to those with a key to the office, which did not include agency staff.