The 5 day inquest touching the death Miss Deseree Fitzpatrick concluded on Friday last with HM Coroner Andrew Bridgeman delivering a narrative conclusion.
Deseree was admitted as a voluntary patient to the Royal Cheadle Hospital operated by the Priory on the 19 January 2022 due to risks of self-harm and for alcohol detoxification. Deseree was just 30 years of age at the time of her death on the 23 January 2022.
Prior to her admission Deseree was living in sheltered accommodation after being the victim of domestic violence. She had suffered a number of significant traumatic events during her life and was diagnosed with Emotional Unstable Personal Disorder (EUPD). Deseree was upbeat upon admission, especially going into the Priory, she felt that she was going to get treatment that only celebrities received and was relieved that she was finally going to get the help she so desperately needed.
On admission Deseree was already in receipt of a number of medications from her GP but was then prescribed a number of additional drugs, the majority of which had a central nervous depressant effect.
The Coroner found that there was insufficient consideration of polypharmacy, that the medication regime was inappropriate and caused Deseree’s death. He found that there were missed opportunities for a review of that regime. The Coroner stated that Deseree was given so much medication that it resulted in profound sedation and the loss of her gag reflex.
The Coroner recorded the medical cause of death as:
1a Aspiration of gastric contents;
1b Due to the combined effects of prescribed drugs.
Deseree died as a result of the significant sedative effect of an inappropriate regime of prescription medication which suppressed Deseree’s gag reflex causing her to aspirate stomach contents during her sleep.
The first paramedic on scene was informed that Deseree was subject to observations every 15 minutes and was last seen breathing at 08:17 before she was discovered unresponsive at 08:23. However, the paramedic observed that Deseree was cold to touch, had what he thought was hypostasis and the onset of rigor mortis which had locked her jaw shut and prevented him from establishing an airway. The paramedic questioned the last time Deseree was seen breathing and was assured that it was 08:17 and so commenced advanced lifesaving treatment.
Despite CPR, Deseree was pronounced deceased at 09:38.
The Pathologist gave evidence at the inquest that Rigor Mortis takes at least 2 to 4 hours to set in so Deseree must have died sometime between 04:30 and 06:30 despite the fact that observations records completed during this time recorded Deseree to be asleep and breathing.
Upon viewing the CCTV footage, it was evident that observations were not conducted in accordance with policy, and some weren’t carried out at all.
Deseree suffered from Acid Reflux and Oesophageal motility which would cause her to vomit in her sleep. Deseree had been sick in her sleep on the 19 January 2022. She then saw a doctor who failed to record the assessment in her notes which was criticized by the Coroner in his findings of fact.
The Coroner found that there were a number of failings which might have possibly led to further action recognising that she suffered from nocturnal regurgitation.
The Coroner stated that there was a clear breakdown in communication between the medical team and nurses and that there were missed opportunities to consider and manage the risk of Deseree vomiting in her sleep.
The Coroner stated:
Record keeping was poor and non-existent at times, particularly the rationale for dispensing PRN drugs being the most important.
He stated that the observation sheets were not completed, and risks were not identified on patients notes. There was no reference to alcohol withdrawal and over sedation and it is imperative that healthcare assistants know the risks and what they should be observing.
The Coroner stated:
Observations are not there to just check patients’ presence, but they seem to be just that, no interaction. Without interaction, sedation will not be recognised and compounded in patient who is sedated. The observations were awfully inadequate, grossly inadequate, but not causative as Deseree would have died within 2 to 3 mins of aspirating the contents of her stomach.
Deseree was receiving medication for alcohol withdrawal which required her breathing to be checked every 4 hours. No such checks were carried out. There were instructions insufficient from medical staff to healthcare nurses.
This was a significant failing; the whole purpose of monitoring breathing is to pick up on over-sedation. On balance I find that there were times when Deseree would have been showing signs of over sedation and there were missed opportunities for this to be addressed.
In short, Deseree died because she had been sedated to such an extent that her gag reflex was lost or suppressed allowing gastric contents to enter her lungs during sleep and this caused her death.
HM Coroner Andrew Bridgeman ended his enquiry by saying to Deseree’s mother;
No parent should have to grieve the loss of their child and for that I am deeply, deeply, sorry.
The family were represented by Gareth Naylor, Head of Inquest Law at Ison Harrison Solicitors and Counsel, Richard Copnall from Parklane Plowden Chambers.
