Maureen Margaret Jarvis · Prevention of Future Deaths report

On 24 August 2018 I commenced an investigation into the death of Maureen Margaret Jarvis aged 72 years. The investigation concluded at the end of the inquest on 10 September 2019. The conclusion of the inquest was ‘naturally occurring ulcer that was not diagnosed until after it had burst’ with the death having resulted from a perforated duodenal ulcer.

(a) Maureen Margaret Jarvis (known as Mandy) was compulsorily detained under section 3 of the Mental Health Act at the George Bryan Centre (GBC) Tamworth. On the 15th August 2018 she was taken to Good Hope hospital where she died on the 17th August 2018 due to the effects of a burst ulcer.
(b) At times staff at GBC were aware of Mandy being in pain. A full physical examination did not take place on admission although this was policy, nor at any other time during the rest of her time at GBC. Mandy did not provide her consent and it was deemed not appropriate to force her. The lack of full physical examination is a possible causative factor in her death. A further consideration is the failure to keep correct and accurate records. The level of personal care Mandy received could have been improved.

During her final admission to the George Bryan Centre Mrs Jarvis did not have a proper medical examination by a doctor. The reasons given for this were that she would not consent and that her condition never warranted this being done on a non-consensual basis. Among other witnesses I heard helpful evidence from the Consultant Psychiatrist ████████ who indicated that this was a difficult area and also from ████████ (the lead author of the Serious Incident Review) who believed there was a policy about this but could not be specific. It strikes me that there should be a clear policy about physical health examination of admitted psychiatric patients and this should be disseminated to all staff involved.