Neil Shastri-Hurst appeared for the son and widow of Michael Nolan who tragically died whilst detained under section 2 of the Mental Health Act 1983 (as amended), instructed by Priya Singh and Christina Jose of Hodge Jones and Allen.

At the time of his death, Michael was a patient on Kelvedon Ward at Basildon Hospital, part of Essex Partnership University Trust (EPUT).

Michael, a much loved family man, had been admitted following a serious attempt to take his own life on 22 June 2022. After being detained under section 2 of the Mental Health Act 1983 (as amended), he was initially monitored on Level 3 (constant 1:1) observations before being stepped down to Level 2 observations (a minimum of four physical observations per hour). The purpose of both Level 2 and 3 observations was not only to observe patients but also engagement with them in order to assess their mental wellbeing.

In addition to physical observation and engagement, EPUT utilised the Oxevision system to monitor vital signs. EPUT’s policy was that Oxevision was not a substitute for conducting face to face engagements with patients on Level 1, 2, or 3 observations.

In the hours before his death, observation and engagement with Michael was not performed in accordance with EPUT’s policy. The Jury heard evidence that, on repeated occasions, Level 2 observations were performed using Oxevision, in contravention of EPUT’s own policy. In some instances, the evidence pointed to Level 2 observations simply not being performed at all.

Michael was subsequently found in cardiac arrest in the en suite bathroom to his room. Despite resuscitation efforts, Michael sadly died. A post-mortem subsequently identified that he had swallowed the lid of a roll-on deodorant.

Following an 8 day Article 2 Jury inquest into his death, the Jury, in its narrative conclusion, found a number of significant and serious failures. These included:

1. “The risk assessments undertaken regarding Michael whilst on Kelvedon Ward were incomplete. Had the level of risk box been completed this may have influenced the decision making on the level of care, observation and engagement”;

2. “Oxevision training was inadequate”, such that it was “ not effectively conveyed to staff” that the system did not provide “an alternative to face-to-face observations and engagements”;

3. “The process of recording and conducting observations and engagement was clearly lacking from some staff…There was no robust mechanism whereby the nurse in charge was monitoring the quality of observations”;

4.      There were “serious concerns regarding the roles and responsibilities of the staff during the nightshift” immediately before Michael’s death;

5. “There were serious failures to carry out effective level 2 observations and engagement on Michael. The HCAs responsible for Michael’s care consistently used Oxevision as a substitute for observations and engagement, and, in many cases, failed to use Oxevision correctly”; and

6.      The observation records had been amended and noted that Michael had been observed in the bathroom when CCTV footage demonstrated that this engagement did not take place.

In reaching its conclusion, the Jury recorded that if “the observations and engagements had been carried out correctly there may have been a different outcome”.

In addition to the failings highlighted above, the inquest heard that the majority of staff responding to Michael’s medical emergency were not up to date with their Basic Life Support (BLS) training and there were significant issues with familiarity with emergency care equipment. This included the bag valve mask, which could not be located in the grab bag despite being present. The inability to locate equipment during resuscitation had been a feature of another inquest involving EPUT and the translucent nature of the bag valve mask was considered to be a factor. Whilst these matters could not be put to the Jury for its consideration, being non-causative in nature, the issues raised did form part of His Majesty’s Coroner’s considerations in relation to the prevention of future deaths.

Whilst satisfied with the reassurances provided by EPUT in relation to improvements in care, His Majesty’s Coroner reserved judgment on issuing a Preventing Future Death report under Regulation 28 in respect to issues around the bag valve mask.

The inquest was reported via a number of news outlets, including Southend Echo, EssexLive, Your Thurrock, and by BBC East’s Health Correspondent Nikki Fox on X.