In the circumstances it is my statutory to report to you: The MATTER OF CONCERN is as follows. The sad facts leading Up to the death of Alice have not been the first set of facts where I have heard about the death of a young mentally unwell patient being cared for on an acute mental health ward and who becomes acutely physically unwell, goes into cardiac arrest and where attempts at cardiac pulmonary resuscitation prove unsuccessful: Post-partum psychosis 1 in 1,000 new mothers suffer from the dreadfully disabling and distressing disorder of postpartum psychosis. [have carefully considered whether to focus in on the care of patients with post-partum psychosis in relation to any PFD report: This is Ido not consider 1 in 1,000 is a low figure. This is a disorder associated with young women and a disorder with a prognosis and one would hope the mortality rate is low. The disorder is an acute psychiatric emergency and carries with it symptoms that can clearly be a8 severe a8 one can conceivably imagine. However, the surrounding Alice's death raise issues involving arguably wider matters than the concentrating on the particular disorder itself I have sufficient concern about a wider issue which warrants the writing of this being pulse acted pulse sleepy long duty because good facts

Prevent Future Death Report (CJA 2009 , Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally: This is: Theidentification ofacutely physically_unwelL patients nursedin an acutc mental health setting__and thercon appropriate_escalation of cre In Alice's case, even before there were signs that she was physically unwell, there was n10 regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health: No serial measurements of her observations meant that abnormalities could not be easily, or at all; identified once occurred. In mental health units the threshold that prompts the use of 'regular vital sign observations appears to be high, and there maybe reasons for that and clearly this is a patient-specific issue. However, identification of patients who are becoming acutely physically unwell does need more attention in general, with Or without reconsidering how readily vital sign observations are ordered Even when the NEWS (previously MEWS) system is in place process which is there to assist in the identification of patients who are becoming acutely unwell it is not always followed_ This is a recurring theme I see as a coroner. Having policies and procedures in place does not appear to be sufficient: Iam aware that Nurse Consultants in Physical Healthcare are now working in acute mental health settings. That scems like a big stcp in the right direction. am told there are very few Nurse Consultants in Physical Healthcare working in mental health settings currently (maybe as few as six). [was impressed with the Nurse Consultant who currently works for the West London Mental Health NHS Trust. Iam aware that remote physiological monitoring of patients in acute mental health settings has been trialled and this may assist in the future: As with the NEWS scoring system, predisposes that staff will accurately usc_interpret andact upon_abnormal observations_appropriately: From what I have scen with the use of MEWS/NEWS scoring, this be the challenge: Nurse Consultants in Physical Healthcare would be able to assist. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths The employment of Nurse Consultants in Physical Healthcare in acute mental health settings will assist in respect oftraining_mental hcalth practitioners such as_ being they good will nurses and healthcare workers in the identification of physically sick patients and thereon the appropriate escalation of those patients care. The installation of remote physiological monitoring at the current time, appears to have potential merit; although it is only as as its operators_ I would be grateful if NHS England would acknowledge my support for the use of Nurse Consultants in Physical Healthcare working in acute Mental Health settings. With or without technological advances to assist staff; the education and auditing of mental health professionals in identifying the acutely sick, and carrying out appropriate action, is vital to prevent future loss of life: YOUR RESPONSE You are under a to respond to this report within 56 days of the date of this report; namely by 14u July 2017. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise YOU must explain why no action is proposed: If you require any further information Or assistance about the case, please contact the Coroner's Officer; COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: Alice's family The West London Mental Health NHS Trust Chelsea & Westminster NHS Foundation Trust The Metropolitan Police Service London Ambulance Service NHS Trust Tam also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner: [DATE] [SIGNED BY CPRONER] 18h 2017 good duty complete May