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  • Prevention of Future Death report: Brooke Martin (9 September 2021)

    Patient Safety Learning
    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Tom Osborne, Senior Coroner
    • 09/09/21
    • Health and care staff, Patient safety leads


    On 11 June 2019 an investigation into the death of Brooke Martin aged 19 started. Brooke was a patient at Isla House, Chadwick Lodge, Milton Keynes and was detained under the Mental Health Act. She had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder. Brooke was found hanging in her room and was taken to Milton Keynes University Hospital where she died on 11 June 2019.


    Brooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room.

    Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to the MDT meeting on 6 June and consideration given to increasing the level of observation. The incident should also have been discussed and disclosed to all members of staff caring for her. On 10 June 2019 Brooke Martin was found secretly fiddling with a bedsheet on two occasions by two different members of staff.. The bedsheet should have been removed and examined, that would have shown that a section of the sheet had been torn off. This would and should have resulted in a full risk assessment and search of her room, that would have resulted in an increase in her level of observations to 1:1 observations. Brooke Martin, if constantly observed or other safety measures put in place would not have been able to tie the ligature that caused her death and would not therefore have died on 11t June 2019.

    Coroner's concerns

    During the course of the evidence it was explained to the coroner that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient.

    This situation should be reviewed to see how access across the NHS can be gained to patient records when required. The coroner was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history. This would not be the case if he had direct access to the records.

    Prevention of Future Death report: Brooke Martin (9 September 2021) https://www.judiciary.uk/publications/brooke-martin-prevention-of-future-deaths-report/
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