Carole Lovett
PFD Report
Historic (No Identified Response)
Ref: 2016-0174
Coroner's Concerns (AI summary)
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:
Sent To
- North Middlesex Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
1 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 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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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.