Health trust admits to ‘letting down’ woman who died in its care

Elmleigh Hospital in Havant.
Elmleigh Hospital in Havant.
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HEALTH bosses have issued a grovelling apology after a woman with bipolar disorder died when she was left to sleep on a hospital floor.

Marion Caroline Croall slept on a duvet on the floor outside her room at Elmleigh Hospital, a psychiatric facility in New Lane, Havant, on the night of April 25, 2013.

The 66-year-old, of Hindhead, Surrey, was admitted into the facility just over a week earlier, on April 17.

But during a three-day inquest into her death, jurors were told how staff failed to adequately check on Ms Croall’s welfare during the early hours of April 26 when she was found dead.

Now after a jury recorded a conclusion of misadventure, Mark Morgan, the head of operations for Southern Health, the group which runs Elmleigh, has said sorry.

He said: ‘Miss Croall died in circumstances that were unacceptable. She had a right to expect better from those who were looking after her and we let her down.

‘On behalf of the trust, I am truly sorry and extend our sympathies to her family and friends.’

The inquest at Portsmouth Coroners’ Court heard how Ms Croall had been ‘irritable’ on the night of her death.

Temporary agency staff had been briefed about her, told she was at times difficult and that it was not unusual for her to sleep on the floor because of her back pain.

The inquest heard that after she fell off her chair at about 11pm, senior staff nurse George Garang attempted to persuade her to go to her room.

When this failed, he allowed her to sleep on the floor outside it, telling the court how he and fellow nurse, Rumbidzai Serima-Fowler would conduct half-hourly welfare checks on her.

However, at about 4.09am the fire alarm in the female ward was set off and Ms Croall was found lying face down on the floor, dead.

When paramedics arrived, they claimed Ms Croall appeared to have been dead longer than 30 minutes, with subsequent post-mortem examinations putting her time of death at about 2am.

The inquest heard how Mr Garang had told Mrs Serima-Fowler to alter the wording on their observation sheet after Ms Croall’s body was found. The original record was disposed of in a shredder.

This revelation prompted a police probe – which was subsequently dropped.

Two post-mortem investigations were carried out.

Toxicology results showed Ms Croall had a ‘potentially fatal’ mix of prescribed drugs in her system.

The impact of the drugs slowed her neural activity and breathing, with pathologist Dr Adnan Al-Badri saying it caused ‘significant depression of her central nervous system’.

‘It became a vicious circle,’ he said. ‘The more deeply unconscious they become the more their breathing is affected and the more the breathing is affected the less oxygen that gets to the brain.’

Fellow pathologist Dr Judith O’Higgins added it would have been ‘impossible’ to predict the impact the drugs would have had.

She concluded Ms Croall died due to a combination of positional asphyxia, respiratory depression due to the drugs and left ventricle failure.

Since the incident, Mr Morgan said there have been ‘significant changes and improvements’ at the ward.

This includes introducing a new high-dependency area to allow the trust to ‘better respond to patients’ needs’.

Cynthia Goldthorpe, paid tribute to friend Ms Croall, saying she was ‘very intelligent’. ‘She was a lovely, lovely woman,’ she said. ‘She never had a bad word to say to anybody.’