Suzanne Roberts · Prevention of Future Deaths report

A seven day Article 2 Jury Inquest was completed on 12th December 2019 into the death of Suzanne Roberts

Miss Roberts was detained as patient under the Mental Health Act, at The Dene, a private hospital in West Sussex She died on 18th October 2015 at the Dene, a sudden cardiac arrest arising out of Acute Kidney Injury, Pyelonephritis, Chronic Dehydration and an underlying condition of a High Output Stoma

Miss Roberts had significant physical healthcare issues arising from her High Output Stoma, which together with other self-harming behaviours, resulted in her admission to the Royal Sussex County Hospital (“RSCH”) in Brighton, East Sussex, on several occasions during her seven week stay at The Dene Her last admission to the RSCH was on 12th October 2015, where she was found to have high potassium and Acute Kidney Injury Due to systems and communications failings between different Departments at the RSCH and within the Department of Trauma and Orthopaedics, Miss Roberts was discharged on 14th October 2015, without knowledge of her initial admission, renal assessment and recommended in-patient treatment, but with blood test results that showed high levels of potassium, which led to heart failure and death on 18th October 2015. The Jury found that there had been neglect

The Jury made factual findings

a) That there was fragmented information sharing between Departments at the RSCH, resulting in a serious failure to be aware of this patient’s needs
b) There was not an effective system in place at the RSCH for the use of this patient’s clinical records
c) There was not an effective system in place at the Trauma and Orthopaedic Department at the RSCH for the use of this patient’s clinical records
d) There was not effective communication between all Departments at RSCH and within the Department of Trauma and Orthopaedics at the RSCH relating to treatment of Suzanne Roberts

And that these probably contributed and caused her death on 18th October 2015

A Senior Consultant at the RSCH gave evidence at the Inquest in December 2019 and described the current system of managing patient records at the RSCH as “sub-optimal” and “flawed” and that a similar death to that of Suzanne Roberts could occur (in the same circumstance as seen in October 2015) in December 2019

The Jury found the management of patient records at the RSCH to be ineffective, as was cross Department communication in relation to patient treatment The Jury also found ineffective communication and ineffective use of patient records within the Department of Trauma and Orthopaedics in relation to patient treatment

Whilst there was evidence that £30m had been recently spent by the Brighton and Sussex Universities Hospital NHS Trust on a failed attempt to create a single electronic patient record, the Inquest revealed that

There were at least three software systems in use by different Departments at RSCH, alongside paper records, and that a portal system, Panda, was also potentially in place In the absence of mandatory rules for the use of those systems or portal, and mandatory quality assurance about data uploaded to those systems or portal, there is a continuing risk of future deaths due to ineffective management of patient records and ineffective communication across departments at RSCH