Mary Ebere Nwanyonyiri · Prevention of Future Deaths report

On the 5th May 2021 I commenced an investigation into the death of Mary Ebere Nwanyonyiri, aged 33 years. The investigation concluded at the end of the jury inquest on 25th November 2022. The conclusion of the inquest was a narrative conclusion:

Mary died following a cardiac arrest that occurred on the 19th April 2021. Her health declined whilst a resident in the care of Goodmayes Hospital. Had there been evidence of physical observations, this may have prevented her sudden decline. The absence of a care plan contributed to her death.

Mary Nwanyonyiri was admitted to Goodmayes Hospital following a deterioration in her mental state on the 9th April 2021. She was an inpatient at the hospital until she was found unresponsive in her room on the 19th April 2021. During the course of her admission, Mary had largely declined medication and vital signs observations. During the course of the 10-day admission to hospital, under section 3 of the Mental Health Act, there was no written care plan for Mary. There was no completed risk assessment document with an associated risk management plan. Mary was found unresponsive in her bedroom on the morning of the 19th April 2021. Post-mortem investigations revealed that she died as a result of Covid-19 infection. The expert witness was unable to fully explain the apparent rapid decline in Mary’s physical condition.

1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved. The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery. Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations.

2. A number of nurses failed to recognise the acute clinical severity of Mary’s condition on the morning of the 19th April 2021. They did not respond to her very concerning clinical state with the necessary urgency.