Dean Bray
PFD Report
No Identified Response
Ref: 2024-0649
Coroner's Concerns (AI summary)
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.
Sent To
- Southern Health Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
20 Jan 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
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
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.