Ratidzai Sangare
PFD Report
Historic (No Identified Response)
Ref: 2016-0195
Coroner's Concerns (AI summary)
Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. Agency staff had limited access to telephones for emergencies.
View full coroner's concerns
_ Healthcare staff were unaware or did not recognise that Mrs Sangare's condition required immediate cardiopulmonary resuscitation, the activation of the alarm, and the summoning of an ambulance (2) Staff did not respond immediately to alarm when it was activated, on the assumption that it was likely to be a behavioural issue or false alarm rather than a medical emergency (3) Access to a telephone was limited to those with a to the office , which did not include agency staff: May key
Sent To
- Oxleas NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
13 Jul 2016
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 21st April 2015 commenced an investigation into the death of Ratidzai Kudakwashe SANGARE, 38. The investigation concluded at the end of the inquest on 17 2016_ The conclusion of the inquest was that Mrs Sangare died from ligature compression of the neck. The jury recorded a narrative conclusion: that Mrs Sangare died between 5.15 and 8.28a.m. on Millbrook Ward. She was found face down with a dressing gown belt around her neck that caused the ligature compression.
Circumstances of the Death
Mrs Sangare was a detained patient with a diagnosis of acute psychotic disorder (in remission) and personality disorder. On the morning of her planned discharge she was found unresponsive on the floor of her room with a dressing gown belt around her neck_ Efforts to resuscitate her and to call for medical assistant were delayed, though it is not possible to determine whether the delay contributed to the cause of death_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.