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Investigation and inquest
On 10 October 2022 I commenced an investigation into the death of Severine Alexia Kelly born on 30 July 1981. The investigation concluded at the end of the inquest on 21 February 2024. The conclusion of the inquest held with jury was that Severine died on 1 October 2022 at Wotton Lawn Hospital Gloucester of food inhalation.
Circumstances of the death
Severine was detained at the time of her death under s.3 Mental Health Act 1983 and accommodated at Greyfriars Psychiatric Care Unit Wotton Lawn Hospital Gloucester. On 1 October 2022, she was provided with a sandwich by a member of the hospital staff. She choked on the sandwich. Various medical professionals attempted to assist, including nurses, paramedics and a doctor, but she died at the hospital.
Coroner’s concerns
The medical training of certain “bank” staff, at the hospital on 1 October 2022, was not up to date.
Staff needed to be aware of the need to update risk assessments and take appropriate action following a medical event that could be injurious to a patient. Specifically, Severine suffered a similar choking incident in 2021.
A doctor, attempting to assist Severine and speak to the 999-emergency service was obliged to leave the patient to use a mobile phone. He did not have the facility of a portable landline telephone which would have meant that he could have spoken to the service without leaving the patient.
A paramedic attending Wotton Lawn hospital was unsure which ward he should attend due to lack of guidance from staff at the hospital. This led to a delay in the paramedic attending on Severine.
There seemed to be uncertainty at which stage of a medical emergency a medical professional should call the ambulance service.
An AED used on the 1 October 2022 appeared not to have a working internal clock.
Information checked against the published report and official responses