Mental health patient's death in Portsmouth sparks 20 changes at Solent NHS

Solent NHS Trust revealed during the inquest of Chantal Egan that it had learnt from her death and taken steps to reduce a similar incident happening again.

Miss Egan, 28, was staying on the Hawthorns ward at St James’ Hospital in Milton, Portsmouth, when she was found by staff with a ligature round her neck on September 24 last year.

She was not breathing and they started CPR before an ambulance was called for assistance.

Miss Egan was taken to Queen Alexandra Hospital where a pulse was established but she died a day later.

During the hearing, at Portsmouth Coroner’s Court, coroner David Horsley summed up the evidence for eight members of a jury following the five-day inquest.

He said Miss Egan had been diagnosed with unstable emotional personality disorder and had spent time in and out mental health facilities.

At the time of her death, the future of where Miss Egan would carry on getting care was being decided.

Mr Horsley said: ‘She had an extensive history of self-harming incidents but when she did, it was in full view of people or she would shout for help.

‘At Hawthorns she was put on 15-minute observations and, we have heard from the evidence, on the day she died she was seen by a member of staff at 2.35pm.

‘Very shortly after, at 2.45pm she was found in her room with a ligature round her neck.’

Mr Horsley said, during the inquest, evidence had called into question the staff’s CPR and their use of an alarm to alert others to the situation.

But in their narrative conclusion the jury found although Miss Egan did not receive basic life support, it did not contribute significantly to her death.

The foreman said: ‘Having placed a ligature round her neck, Miss Egan may have lost consciousness between 10 to 15 seconds and suffered irreversible brain damage in four to five minutes.

‘We considered the inexperience of hospital staff, from the inconsistency of training, the uncertainty of what alarm to use and the uncertainty of proper use of all elements of resuscitation equipment. We were unable to reach a conclusion if this contributed to Miss Egan’s death.’

Speaking after the conclusion, Matthew Hall, from Solent NHS Trust which runs St James’ Hospital, said an independent inspector had made 20 recommendations to the trust following an investigation.

He said 19 had been fully complied with the other one had been adapted to fit in with the trust’s current programme.

‘The investigator made a series of 20 recommendations in regards to improvements that she would like to see in practice,’ he said.

‘They have been in the areas of giving life support, how we deal with people with unstable emotional personality disorder and staff training.’

As part of the recommendations, staff at the facility now take part in simulations using dummies and actors suffering cardiac arrest, anaphylactic shock and who have self-harmed to help with their confidence and experience in real-life situations.

Mr Hall said the simulations started off once a week and then once a fortnight to ensure all staff members had the chance to do the training.

He added Solent had invested thousands of pounds into new defibrillators and training mannequins.