Amanda Gibbens · Prevention of Future Deaths report

I opened an inquest into the death of Amanda Gibbens. The investigation concluded at the end of the inquest on 21 February 2022.

The medical cause of death was:
Ia Hypoxic brain injury
Ib Asphyxiation

Ms Gibbens died on 13 July 2020 at Stoke Mandeville Hospital, Buckinghamshire. Ms Gibbens had been detained under Section 2 of the Mental Health Act at Ruby Ward at the Whiteleaf Centre, managed by Oxford Health NHS Foundation Trust. Whilst an in-patient, the deceased made attempts to self-harm including by using a ████████
████████ and making multiple attempts to ████████
████████. Whilst she was in the de-escalation room on Level 3 constant observations, she obstructed her ████████ – this action was not witnessed. She then suffered a cardiac arrest and despite resuscitation efforts she did not survive.

1. Using a monitor screen for Level 3 constant “within eyesight” enhanced observations.
The jury found in this case that the deceased could not be seen at all times whist in the de-escalation area, because male healthcare staff moved from observing the female patient from their position in the doorway of the de-escalation room, to view via the monitor in the corridor, when the patient moved into the bathroom, to increase her privacy. Although the Observation policy has been updated since this death in July 2020, by the time of the inquest, the use of the monitor for performing L3 observations was not specifically addressed or prohibited. Although the head of nursing was clear that this should no longer be happening in practice, the current Matron of Ruby ward gave evidence that this was still happening, and although it was now being ‘discouraged’, it was not prohibited.

2. Searching bedrooms on Ruby ward for prohibited items
The evidence in this case demonstrated that the deceased had prohibited items in her bedroom on Ruby Ward, including a ████████
████████ The search of the patient environment in July 2020 was not effective in identifying and removing items which could be used for self-harm by a detainee patient under the Mental Health Act, who was at risk of self harm. The evidence heard at the time of the inquest in February 2022 was that the bedroom searching process does not always include looking into or underneath a patient’s property in their room for concealed items, although some changes to the method and recording of searches are intended. A previous Report to Prevent Future Deaths to the Trust dated April 2019 also identified that the search process on Ruby ward was not effective.