Jury finds that Roxanne Brown, a mental health in-patient, died as a result of multiple causative failings and neglect by hospital staff

Roxanne Brown - known as ‘Roxy’ - collapsed and died on 2nd November 2019 from a pulmonary embolus caused by a deep vein thrombosis in her right leg. At the time of her death, she was detained under section 3 of the Mental Health Act in a mental health hospital. Despite having been obviously unwell for days – and repeatedly showing abnormal vital signs – nursing staff failed to escalate her care or send her to A&E.

Roxy had a diagnosis of treatment resistant paranoid schizophrenia and was admitted to Shrewsbury Court Independent Hospital (SCIH) in March 2019. She made good progress and the hope was for her to be reintegrated into the community.

In October 2019, she became physically unwell with a productive cough and an elevated pulse rate. She was taken by a support worker to a GP at the local practice, who diagnosed her with a chest infection. However, the hospital staff did not inform the GP that she had had a persistently raised pulse rate for days before (ranging from 121 to 133) and, if he had known this, he would have sent her to A&E. The jury found that, had this happened, it would have averted her death. 

Nevertheless, the GP provided Roxy and the support worker with ‘worsening advice’ (i.e., if she got worse within 24-48 hours, she should be taken straight to A&E). However, this was not recorded in the medical records at the hospital or adequately communicated to the nursing staff on the ward. The jury found this ‘adversely impacted’ on her care.

In the following days from 28th October – 2nd November 2019, Roxy’s condition did deteriorate, but staff did not take her to A&E as per the GP’s worsening advice. She had two successive falls, as well as dizziness and vomiting. She also had multiple abnormal vital signs readings, which were in the ‘amber’ and ‘red’ sections of the hospital MEWS chart. Despite this, no follow-up readings were taken and there was no escalation.

The jury found that from 28th October 2019 there was a failure by the hospital staff to follow the MEWS guidelines resulting in ‘inadequate care and a failure to escalate’. There were ‘several missed opportunities for Miss Brown’s care and treatment to be escalated, including transfer to A&E’.

On the evening of 2nd November 2019, Roxy collapsed. Although CPR was given by staff, she could not be resuscitated and passed away.

The jury found that the death was contributed to by neglect.

The Coroner will be issuing a Prevention of Future Deaths (PFD) report to the Nursing and Midwifery Council (NMC) regarding the training and standards of registered mental health nurses in the context of the findings of the jury.

The family was represented by Matthew Turner instructed by Tessa Hutchinson and Keiu Kikas of GT Stewart Solicitors & Advocates.

The Coroner was HM Assistant Coroner for Surrey, Darren Stewart OBE. 

The other Interested Persons were Shrewsbury Court Independent Hospital (Whitepost Health Care Group) and Holmhurst Medical Centre.