SEBASTIAN VAUGHAN DAVIES · Prevention of Future Deaths report

On 5 AUGUST 2013 an investigation commenced into the death of SEBASTIAN VAUGHAN DAVIES, 23. The investigation concluded at the end of the inquest on 25 MARCH 2014 held over two days with a Jury. The conclusion of the inquest Jury was that the medical cause of death was 1a Cerebral ischaemia, mult-system organ failure, and developing bronchopneumonia and 1b Opiate excess and they gave a narrative conclusion as follows:
“Sebastian died due to an excess of opiates obtained from an unknown source. We believe that procedures operated at the Norvic Clinic could not have prevented his death”.

At the time of his death Sebastian Vaughan Davies was a detained patient under the Mental Health Act at the Norvic Clinic. On 24 July he was assessed suitable for unescorted leave under a.s17 authority in place. On his return no illicit substances were discovered on his person. He retired to bed at 11:00pm. He was unresponsive but breathing the following morning 25 July 2013. Paramedics attended and he was taken to the Norfolk and Norwich Hospital. Sadly he remained unconscious and died at the hospital on 4 August 2013.

Evidence was given at the Inquest that there was a system of hourly observation checks on patients in their rooms during the course of a night shift. These consisted of shining a torch through the window in the door to the room and looking and listening for signs of breathing. However it was not routinely part of such observations to check whether the patient had moved or appeared to have remained immobile for an extended period unless there was a particular concern which there was not in Sebastian’s case. The observations were done in pairs and shared between the staff nurse on duty and the three support staff. However the same individuals did not carry out all the observations on any particular patient. There was therefore a lack of continuity. It was confirmed it was possible for a patient to be breathing but unconscious. Sebastian was heard to be snoring. Sebastian when found to be unresponsive at around 08:30 hours had a crush injury to his right arm. It was therefore apparent that he had been lying immobile on his arm for some extended period of time.

Notwithstanding the Jury’s conclusion that the procedures at the Norvic Clinic could not have prevented Sebastian’s death I am nevertheless concerned that a failure to specifically check whether a patient has moved or rather remained immobile for an extended period on hourly observations (thereby indicating that perhaps they may have fallen unconscious) could in the future give rise to a preventable death and therefore there is a risk of future deaths occurring and that therefore a review may need to be undertaken of the procedure for night time hourly observations to specifically include whether a patient has moved or remained immobile for an extended period and whether a system can be devised to give better continuity of those undertaking observations of individual patients.