Neeshat Dalal · Prevention of Future Deaths report

The inquest was opened on 23.12.22 and was resumed with a jury on 27.05.2026 – 02.06.2026.

The jury made the following findings within a narrative conclusion:

Neeshat Dalal was admitted to Heathfield Ward, Eastbourne District General Hospital on 30.11.22 under S2 Mental Health Act 1983 for the treatment of severe depression. She was having difficulty in eating and drinking and underwent 3 courses of ECT on 6th, 9th and 13th December 2022. She collapsed during the anaesthetic and was transferred to A&E resus department at Eastbourne District General Hospital at approximately 1pm on 13.12.22. She stayed there until the early hours of the following morning, having been reviewed by the anaesthetic, medical and ITU teams. She was transferred to the AMU at 0217hrs on 14.12.22 after varying NEWS scores, but with an increasing respiratory rate and heart rate. She arrested at 0330hrs and in spite of 8 cycles of CPR, her death was confirmed at 0510hrs.

Inadequate consideration was given by SPFT staff that Neeshat was unable to eat or drink due to vomiting, rather than refusing to eat in order to end her life. Neeshat's nutritional needs were not appropriately met. She required support from a dietician and a more timely referral to the gastroenterology team. The consultant psychiatrist and anaesthetist did not have satisfactory medical information for Neeshat prior to the ECT treatment on 13.12.22, and so postponement was not considered in light of this.

ESHT did not consider the need to administer vasopressors between 1338hrs - 2200hrs on 13.12.22. ESHT staff failed to move Neeshat to HDU earlier than 0217hrs on 14.12.22.

These conclusions about Neeshat's care may possibly have contributed to the cause of her death.

Neeshat Dalal began to complain of difficulty in eating and drinking in September 2022. She also became depressed at this time and made 3 attempts to end her life with an insulin overdose. On the third attempt she was admitted to East Surrey Hospital on 14.11.2022 and sectioned under S2 MHA 1983 where she remained until a bed could be found in a psychiatric inpatient ward. She was transferred to Heathfield Ward at Eastbourne District General Hospital which is part of Sussex Partnership Foundation Trust where she remained, undergoing 3 treatments of ECT until she collapsed during the 3rd session on 13.12.2022 and was admitted to the Emergency Department of Eastbourne District General Hospital which is part of East Sussex Healthcare NHS Trust. She remained in Resus in the Emergency Department for 14 hours before being transferred to the Acute Medicine Unit where she died several hours later.

Funding is required for the specific provision of appropriately qualified dieticians who can meet the nutritional needs of inpatients undergoing psychiatric care in SPFT and in other Trusts where such support does not already exist.