Source · Prevention of Future Deaths
Carole Lovett
Ref: 2016-0174
Date: 6 May 2016
Coroner: Andrew Walker
Area: London Greater North
Responses identified: 0 / 1
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Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded to by senior staff, and no consideration for alternative patient monitoring.
Date
6 May 2016
56-day deadline
1 Jul 2016 est.
Responses identified
0 of 1
Coroner's concerns
Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded to by senior staff, and no consideration for alternative patient monitoring.
View full coroner's concerns
Way and and and injury May `
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) The level of competence and training of staff working in the Acute Assessment Unit with regard to the use of NEW Score and communication between all levels of staff: That when the monitoring equipment alarmed this did not result in senior staff attending: No consideration was given, when the alarms were continuously sounding; for alternate forms of monitoring:
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) The level of competence and training of staff working in the Acute Assessment Unit with regard to the use of NEW Score and communication between all levels of staff: That when the monitoring equipment alarmed this did not result in senior staff attending: No consideration was given, when the alarms were continuously sounding; for alternate forms of monitoring:
Report sections
Investigation and inquest
On the 2nd June 2015 opened an investigation touching the death of Carole Rita Lovett aged 63 years old. The inquest concluded on the 22d February 2016 The conclusion of the inquest was Narrative the medical case of death was Ia Bronchopneumonia 1(b) Hypoxic brain complicating hypoxic cardiac arrest; 1(c) Clozapine associated myocarditis and Schizophrenia under paragraph 2,
Circumstances of the death
Having become unwell Carole Rita Lovett; a patient under Section 3 of the Mental Health Act 1983 at St Ann's Hospital was transferred to Northwick Park Hospital on the 16th May 2016. Mrs Lovett had developed a myocarditis as a consequence of the use of Clozapine medication. Mrs Lovett was placed in the Acute Assessment Unit of the hospital where the deterioration of her condition continued until she was found un-responsive in her bed at 14.35 in the early afternoon, Mrs Lovett was resuscitated and transferred to the Critical Care Unit where she died on the 31st
Action should be taken
In my opinion action should be taken to prevent future deaths believe you [ANDIOR your organisation] have the power to take such action:
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Report details
- Reference
- 2016-0174
- Date of report
- 6 May 2016
- Coroner
- Andrew Walker
- Coroner area
- London Greater North
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: 1 Jul 2016 (estimated).
Sent to
- North Middlesex Hospital