On 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
Yvonne had experienced mental health problems since childhood and was considered originally to have a personality disorder. She was treated by mental health services for many years and had several inpatient admissions, some of which were compulsory. After a period of self-neglect and refused admission, Yvonne was finally detained under the Mental Health Act on 27 January 2020 at Park House Psychiatric unit, Manchester. On admission she was found to be significantly malodorous and have several long-standing serious deep infected ulcers. She had to be transferred to the acute hospital for assessment and treatment where her condition gradually improved and she was given prophylactic venous thromboembolism (VTE) medication until she was medically fit enough to be discharged back to the psychiatric unit on 12 February 2020.
When she was readmitted, despite discharge information from the acute hospital stating that she had been treated with VTE prophylaxis and despite Yvonne fulfilling several trigger criteria, a VTE risk assessment was not undertaken in accordance with the detaining authorities’ policy. There was a failure to monitor her condition and make appropriate records or an action and management plan and she did not have further mental capacity assessments. On 19 February 2020 she was again detained and on the morning of 23 February 2020, she had a cardiorespiratory arrest and was resuscitated for a brief period of time before being taken to the emergency department of North Manchester General Hospital. Further attempts at resuscitation proved unsuccessful and she was pronounced dead due to a pulmonary thromboembolism.
The Greater Manchester Mental Health NHS Foundation Trust (GMMH) serious incident investigation failed to establish:
- whether the responsible clinician, junior doctors or nursing staff were aware of the trusts VTE policy and if not, why not.
- if they were aware of it, why was it not complied with.
- whether there was an awareness and compliance with the policy Trust wide.
It also failed to identify, acknowledge or be aware of the death of a patient in 2016 from a VTE at Park House unit.
In their report, the Coroner raised the following matters of concern:
- There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed.
- It did not appear that all permanent or locum clinical and nursing staff Trust-wide were aware of the VTE policy and how it should be implemented including initial assessments and reassessments of the risks as well as consequent medical management.
- There was no regular audit of compliance with the VTE policy.
- There was no training programme to ensure familiarity and compliance.
A copy of the report was sent to the Chief Coroner.
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