• Staff at independent mental health unit given extra training in dealing with emergencies
  • Extra training comes after coroner wrote to the firm outlining failures linked to the death of a patient
  • Inquest found James O’Brien died of natural causes, but the jury said the emergency response from hospital staff was “inadequate”

Staff at an independent mental health unit are being given more training in handling emergencies after a coroner reported a catalogue of failings which led to a patient’s death, HSJ has learned.

James O’Brien had been a patient at the Churchill Hospital in Lambeth for about 18 months after being detained under the Mental Health Act 1983, when he was found collapsed in his room on the night of 8 December 2015.

Staff at the hospital tried to resuscitate the 25-year-old and called an ambulance, which took him to St Thomas’ Hospital where he died on 9 December.

An inquest into Mr O’Brien’s death, which concluded in March 2017, heard he died from “sudden cardiac death in schizophrenia” and the coroner ruled his death was natural causes.

However, assistant coroner for inner South London Philip Barlow wrote to the Cambian Group – which ran the hospital when the death occurred – to outline a number of concerns with the service in the wake of Mr O’Brien’s death.

The provider was given until the beginning of May to respond to the criticism.

Mr Barlow said the jury concluded that “when Mr O’Brien was found to have collapsed the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference”.

He said there could be a risk of future deaths unless action was taken and highlighted several failures surrounding Mr O’Brien’s death including:

  • failure to press the alarm;
  • delay in starting resuscitation;
  • delay in calling an ambulance;
  • delay in bringing the defibrillator, which was then not attached appropriately;
  • “inadequate” information was given to the London Ambulance Service;
  • failure to ensure that staff were adequately trained to respond to an emergency situation;
  • failure to provide adequate induction to staff; and
  • the agency nurse in charge of the ward was called shortly before the shift started, was unfamiliar with the ward and did not have time to read patients’ care plans before starting their duties.

Mr Barlow added: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.”

Cambian Adult Services – now owned by Cygnet Health Care – told HSJ it had provided Mr Barlow with full and detailed response to his concerns.

A spokeswoman said a number of changes have been made, including:

  • all staff being required to undertake online training in responding to emergencies;
  • creating protocols for the hospital to ensure staff now how to raise the alarm, who should respond and use radios;
  • reviewing the induction process for new staff;
  • committing to no longer employing agency staff on an ad hoc basis; and
  • developing an agency nurse induction protocol for staff booked at short notice.

She added: “Subsequent to the death of Mr O’Brien this hospital has been inspected by the Care Quality Commission with an overall rating of good. Patient care remains our top priority, and we are committed to continuously improving our procedures, protocols and training, which we recognise are all critical to providing the highest standards of healthcare.”