Gary Ottway

1. Though Mr Ottway was meant to be under constant nursing observation, not only was he in cardiac arrest but he was also cold and exhibiting hypostasis when he was found. This appears to indicate that either the nursing observation was not constant, or it was not effective. I appreciate that the trust is putting in place a new IT system to monitor signs of life, but nevertheless basic nursing observations must be performed competently.

When the senior duty nurse and the nurse undertaking continuous observation noted that they could not see evidence of respiration, they did not immediately enter the seclusion room where Mr Ottway lay, because they deemed that unsafe following his earlier violent behaviour.

2. The senior duty nurse told me at inquest that he could not be sure that Mr Ottway was not holding his breath, though he had never done this and there was no evidence that he was doing so now.

3. The senior duty nurse also told me that the visibility through the Perspex panel was poor, though he had never brought this to anyone’s attention and did not do so after Mr Ottway’s death.

4. The senior duty nurse told me that the nurses would not enter the seclusion room until the rapid response team was present, but he did not call the rapid response team as soon as he suspected that Mr Ottway was not breathing. Instead, he started by going to get one of the other nurses, which took a couple of minutes; then he rang the duty doctor; and only after that did he radio for the rapid response team.
5. The junior doctor was the last person to attend the resuscitation and told me he did so after the rapid response team, yet no one had entered the seclusion room by the time he arrived.

It may be that there was a (perhaps unconscious) reluctance to enter the room without a doctor, despite the presence of the rapid response (nursing) team. But by the time the junior doctor got to the door and immediately identified that Mr Ottway was not breathing, at least six and a half to seven minutes had elapsed since the first two nurses saw no evidence of respiration. This was well outside the three to four minute window of opportunity for resuscitation without inevitable brain damage or death.

6. In the six and a half to seven minutes before the junior doctor arrived at the seclusion room, the emergency grab bag had not. That took another 30 seconds, though to retrieve it was only a three minute round trip from the room where the nurses who had first identified the lack of respiration were waiting.

7. The junior (and only) doctor called to assist in the attempted resuscitation was not familiar with the contents of the emergency grab bag, told me that it would not have occurred to him to ask for any equipment to assist with ventilations other than a pocket mask, and explained that he was not trained in giving adrenaline or any other medicines for resuscitation.

As he was the only medical resource available in the case of an emergency, these seem significant gaps.

8. When paramedics arrived, they found that chest compressions were being given (by nursing staff) to Mr Ottway’s abdomen instead of his chest, thus rendering them ineffective.