Psychiatric Patient’s Death Linked to Nurses’ Failure to Respond for Over 10 Hours

A coroner has stated that a patient in an NHS psychiatric facility passed away following a period exceeding 10 hours during which nurses did not address his breathing difficulties. Dean Bray, aged 47, succumbed to acute heart failure on December 29, 2021. At the time, he was located in a seclusion room within Hamtun ward at Antelope House in Southampton. An inquest jury determined that the nurses’ “gross failures” and neglect were causative factors in his death. Southern Health, which operated the unit at the time and is now known as Hampshire and Isle of Wight Healthcare NHS Foundation Trust, indicated it was addressing concerns brought forward by the coroner. According to Hampshire coroner Rachel Spearing, Mr. Bray’s condition started to worsen around 21:45 GMT on December 28. She noted that nurses did not “adequately act upon and escalate Dean’s high respiratory rate” until 08:00 on the subsequent day. The inquest jury’s narrative conclusion stated: “There was a gross failure to escalate Dean’s deteriorating physical presentations… based on inadequate monitoring of Dean’s physical health and a lack of recognition of Dean’s medical emergency.” The jury further concluded: “On the balance of probabilities, but for the gross failures, Dean’s life probably could have been prolonged.” In a Prevention of Future Deaths report, the coroner expressed concern regarding delays paramedics experienced in reaching Mr. Bray due to not being advised of the optimal route to the ward. She also noted the absence of an external phone line for making a 999 call from the seclusion room. In a statement, the NHS trust declared: “We offer our deepest sympathies to Dean Bray’s family and loved ones. “We are committed to addressing the concerns raised during the inquest and to continuously improving patient safety.”We will now provide a detailed response to the coroner, outlining the actions we are taking and when they will be completed.”