Siân Frances HEWITT · Prevention of Future Deaths report

On 11/04/2019 I commenced an investigation into the death of Siân Frances HEWITT aged 25. The investigation concluded at the end of the inquest on 05 March 2020. The conclusion of the inquest was:

I a Massive Pulmonary Thromboembolism

I b

I c

II

On admission to the Campbell Centre Milton Keynes on the 13th March and during the period of her admission 2019 there was a failure to carry out a VTE risk assessment this was in breach of the CNWL protocol. There was no plan put in place for adequately maintaining and monitoring her fluid intake There was a delay in administering intra-muscular Aripiprazole that resulted in her mania not being brought under control There was a lack of close ongoing review of her care by a consultant psychiatrist. When Sian failed to respond to her treatment there was a failure to escalate her care and involve more senior members of the care team. There were multiple opportunities to realise that Sian had become unwell on 6th April 2019 that were missed and therefore here was a failure to start effective CPR

My narrative conclusion at the End of the inquest was:

Sian Hewitt died, on 6th April 2019 at Milton Keynes University Hospital where she was taken after collapsing on Willow Ward at the Campbell Centre, there was a failure to recognise how seriously ill she had become and this resulted in lost opportunities to treat her appropriately that may have prevented her death. There was a failure to appropriately treat her to control her mania and a failure to assess, recognise or treat the risks of her developing a pulmonary embolism and these failure’s may have caused or contributed to her death.

It would appear from the circumstances of Ms Hewitt’s death that the NHS are unable to provide a place of safety for those who are suffering from Asperger’s syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar. The Campbell Centre in Milton Keynes was not an appropriate placement and I believe this matter should be looked at by NHS England and for more appropriate provision to be made for such patients.