Source · Prevention of Future Deaths
Dean Bray
Ref: 2024-0649
Date: 25 Nov 2024
Coroner: Rachel Spearing
Area: Hampshire, Portsmouth & Southampton
Responses identified: 0 / 1
View PDF
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.
Date
25 Nov 2024
56-day deadline
20 Jan 2025 est.
Responses identified
0 of 1
Coroner's concerns
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.
View full coroner's concerns
Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House.
Report sections
Investigation and inquest
On 12 January 2022 I commenced an investigation into the death of Dean John Mark Anthony BRAY aged 47. The investigation concluded at the end of the inquest on 11 November 2024. The conclusion of the inquest was that: Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamtun Ward where there was a failure to adequately act upon and escalate Dean's high respiratory rate by nursing staff over the 28th and 29th December 2021
Circumstances of the death
Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamtun Ward where there was a failure to adequately act upon and escalate Dean's high respiratory rate by nursing staff over the 28th and 29th December
Similar PFD reports
Related inquiry recommendations
Southport Inquiry
Out-of-school settings guidance update
Southport Inquiry
Police use of unarmed officers in immediate threat
Southport Inquiry
Second Force Incident Manager support
Southport Inquiry
NWAS Major Incident declaration procedures
COVID-19 Inquiry
Pandemic Decision-Making Framework
COVID-19 Inquiry
Leadership Succession Arrangements
COVID-19 Inquiry
Central Emergency Taskforces
COVID-19 Inquiry
Civil Contingencies Act Review
COVID-19 Inquiry
Devolved Nations COBR Attendance
COVID-19 Inquiry
Four Nations Pandemic Structure
Report details
- Reference
- 2024-0649
- Date of report
- 25 November 2024
- Coroner
- Rachel Spearing
- Coroner area
- Hampshire, Portsmouth & Southampton
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Jan 2025 (estimated).
Sent to
- Southern Health Foundation Trust