Benjamin Thomas Brown · Prevention of Future Deaths report

On the 25th Day of July 2015 I opened an investigation touching the death of Benjamin Thomas Brown, 35 years old. The inquest concluded on the 10th March 2016. The conclusion of the inquest was Natural Causes, the medical case of death was 1a Sudden Cardiac Death due to Cardiac Arrhythmia and under paragraph 11 Schizophrenia, Fatty Liver Disease

Benjamin Thomas Brown was a patient on Avon Ward at the Dennis Scott Unit at Edgware Community Psychiatric Hospital detained under section 2 of the Mental Health Act.

Mr. Brown had a sixteen-year history of treatment resistant Schizophrenia.

Mr. Brown was admitted to Edgware Community Hospital on the 18th July 2015.

Mr. Brown was on 15-minute observations the last of which was recorded 8.15.

A Registered Mental Health Nurse from an agency was not told about the need for 15 minute observations and having taken hourly observations was pressured into making entries in the Patient Observation Records for times when Mr. Brown was not observed.

There were other entries on the Patient Observation Records that having been checked with CCTV evidence confirmed that entries had been made into the Patient Observation Records when no observation had been made.

An entry at 8.30 was entered after Mr. Brown was found to be unresponsive at 8.45am

The time that Mr. Brown suffered a cardiac arrest is likely to have been between 5am and 8.45am .

Resuscitation was initially provided with nursing staff and the duty doctor and then by the London Ambulance Service who arrived at the Dennis Scott Unit at 9.15 am.

Mr. Brown was recognized as having died at 10.06

It is likely that the identification of the cardiac arrest was identified outside the time window for successful resuscitation.

1, The auditing of those persons carrying out 15 minute observations.

2. Training of staff for resuscitation in the event that a patient collapses.

3, The auditing for the prescription and management of clozapine.