Jake Edmund Lee · Prevention of Future Deaths report

On 5 July 2019, I commenced an investigation into the death of Jake Edmund Lee aged 35 years, the investigation concluded at the end of the inquest on 21 February 2020. The conclusion of the inquest was narrative stating that Mr Lee had not had prophylactic heparin since his arrival at rehab and that staff did not commence CPR when he collapsed. He died from 1a) Pulmonary Embolism 1b) Infarction of Spinal Cord.

Mr Lee suffered an infarct of his spinal cord resulting in loss of feeling and immobility below the waist. Whilst in hospital he was given daily heparin, when he was discharged to a rehab unit this was discontinued. The day before his death a prescription for heparin was written. When Mr Lee collapsed, the trained nurse in charge asked an HCA to call 999 which he did. The nurse did not flatten the bed to put Mr Lee into the recovery position, she did not know that his bed had a special device on it to enable CPR, despite having worked at the unit for 4 years. She then left an unresponsive patient in the care of an unqualified person to make another call to 999. She did not accept that she should have stayed, she displayed no indication in her evidence that she knew what to do in the event of an emergency and she panicked. A friend of Mr Lee (a paramedic) stated that this nurse had said “I’m too old to do CPR”. This was disputed by the nurse who said Mr Lee was still breathing (agonal) but snoring and he was too heavy for her to move to the floor. When paramedics arrived, they described Mr Lee as cyanotic and not breathing. There was a delay of some time in emergency treatment being begun. The nurse appeared in evidence as being unsure or untrained in CPR and displayed a marked reluctance to stay and attend to Mr Lee as the only trained nurse on duty. In this instance, any intervention by her is unlikely to have been successful but I believe that if any other emergencies occur whilst she is on duty the same situation will occur and another patient may have a collapse which is reversible.

(1) Inability, lack of training/experience of nurse in charge to deal with an arrest/collapse of a patient. Clear panic in the face of an emergency.
(2) Nurse leaving collapsed patient in care of untrained HCA whilst she made an unnecessary second phone call, she denied that there was a phone she could have used in his room.
(3) Her lack of knowledge about the special bed which Mr Lee had, which allowed CPR on the bed and her stating that she put Mr Lee into the recovery position when he was semi recumbent, she did not flatten the bed and she did not do a mouth sweep to see if his airway was occluded by his tongue.