Prevention of Future Deaths report: Morgan-Rose Hart (28 December 2023)

Summary

Morgan-Rose Hart died after she was found unresponsive while being detained under section 3 of the Mental Health Act at the Derwent Centre at the Princess Alexandra Hospital in Essex. Morgan-Rose was last clinically observed at 14.06 on 6 July 2022 and in between the last observation and when Morgan-Rose was discovered the Coroner notes that multiple failings in her care took place, including consecutive hours observations being incorrect and falsified.

Content

The Coroner raised a number of matters of concern in relation to the Trust’s investigation report into Morgan-Rose’s death, stating that:

• The Trust investigation was materially incomplete and there was a lost an opportunity to understand concerns of the Family, acknowledge errors and learn lessons from the circumstances of the death.
• The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed.
• The investigation did not sufficiently escalate concerns about staff observations, which were shown by CCTV footage to have been recorded incorrectly.
• The investigation did not sufficiently look into security issues raised by this case.

The Coroner also raised the following matters of concern in relation to this case:

• There was a lack of clarity as to whether patients were permitted or not to have belts on Chelmer Ward, relating to the potential risk of self-harm.
• Morgan-Rose attempted to secure unescorted leave on the morning of her death, her Responsible Clinician had only authorised escorted leave. This was not escalated to the nurse in charge and the Responsible Clinician was not informed.
• Evidence was heard that an Oxevision alert is triggered if a person is in the bathroom for more than 3 minutes and staff are required to complete an in-person check. Morgan-Rose was left in the bathroom unobserved for approximately 50 minutes. It was not clear from the evidence how the Trust proposes to ensure compliance in respect of this duty.
• The quality of record keeping was acknowledged to not be appropriate by nurses and senior staff during evidence, yet it had been signed off.
• Observations sheets for vulnerable detained mental patients were signed off by nurses in charge as being appropriate despite an absence of any recorded therapeutic engagement.
• There were omissions in the recording of food and fluid charts required by the Responsible Clinician for a patient who was losing weight with a diagnosis of Body Dysmorphic Disorder. The Responsible Clinician’s evidence was that the absence of appropriate food and fluid charts for other patients was an ongoing issue on Chelmer Ward that had been raised with nursing staff.
• Staff entries in patient observations sheets should have given rise to a concern that some staff may have been using Oxevision not just as an adjunct to face-to-face observations, but instead of them. This remains a concern.