Dean John Mark Anthony BRAY · Prevention of Future Deaths report

On 12 January 2022 I commenced an investigation into the death of Dean John Mark Anthony BRAY aged 47. The investigation concluded at the end of the inquest on 11 November 2024. The conclusion of the inquest was that:

Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamptun Ward where there was a failure to adequately act upon and escalate Dean's high respiratory rate by nursing staff over the 28th and 29th December 2021

Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamtun Ward where there was a failure to adequately act upon and escalate Dean's high respiratory rate by nursing staff over the 28th and 29th December 2021

Narrative Conclusion
The Jury’s conclusion is Natural Death contributed to by Neglect. There was a gross failure to escalate Dean's deteriorating physical presentations on 28th December after 21:43 up until 08:00 on 29th December 2021, based on inadequate monitoring of Dean's physical health and a lack of recognition of Dean's medical emergency which, on the balance of probabilities but for the gross failures, Dean's life probably could have been prolonged.

Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House.