Sebastian Davies
PFD Report
Historic (No Identified Response)
Ref: 2014-0139
Coroner's Concerns (AI summary)
Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.
View full coroner's concerns
Jury Jury: and
Evidence was given at the Inquest that there was a system of hourly observalion checks on patients in their rooms during the course of a night shift These consisted of shining a torch through the window in (he door to the room and looking and listening for signs of breathing: However it was not roulinely part of such observations to check whether the patient had moved or appeared to have remained immobile for an extended period unless (here was a particular concern which lhere was not in Sebastian'$ case. The observations were done in pairs and shared between the staff nurse on and the three support staff. However the same individuals did not carry out all the observations on any particular patient: There was therefore a lack of continuity. It was confirmed it was possible for a palient to be breathing but unconscious. Sebastian was heard to be snoring: Sebastian when found to be unresponsive at around 08.30 hours had a crush injury to his right arm_ It was lherefore apparent that he had been lying immobile on his arm for some extended period of time: Notwithslanding the Jury's conclusion that the procedures at the Norvic Clinic could not have prevented Sebastian's dealh am nevertheless concerned that a failure to specifically check whether a patient has moved or rather remained immobile for an extended period on hourly observalions (lhereby indicaling that perhaps they may have fallen unconscious) could in the future give rise to a preventable death and therefore' there is a risk of future deaths occurring and that therefore a review may need to be undertaken of the procedure for night time hourly observations to specifically include whether a patient has moved or remained immobile for an extended period and whelher system can be devised to give better continuity of those undertaking observations of individual patients_
Evidence was given at the Inquest that there was a system of hourly observalion checks on patients in their rooms during the course of a night shift These consisted of shining a torch through the window in (he door to the room and looking and listening for signs of breathing: However it was not roulinely part of such observations to check whether the patient had moved or appeared to have remained immobile for an extended period unless (here was a particular concern which lhere was not in Sebastian'$ case. The observations were done in pairs and shared between the staff nurse on and the three support staff. However the same individuals did not carry out all the observations on any particular patient: There was therefore a lack of continuity. It was confirmed it was possible for a palient to be breathing but unconscious. Sebastian was heard to be snoring: Sebastian when found to be unresponsive at around 08.30 hours had a crush injury to his right arm_ It was lherefore apparent that he had been lying immobile on his arm for some extended period of time: Notwithslanding the Jury's conclusion that the procedures at the Norvic Clinic could not have prevented Sebastian's dealh am nevertheless concerned that a failure to specifically check whether a patient has moved or rather remained immobile for an extended period on hourly observalions (lhereby indicaling that perhaps they may have fallen unconscious) could in the future give rise to a preventable death and therefore' there is a risk of future deaths occurring and that therefore a review may need to be undertaken of the procedure for night time hourly observations to specifically include whether a patient has moved or remained immobile for an extended period and whelher system can be devised to give better continuity of those undertaking observations of individual patients_
Sent To
- Norvic Clinic
Response Status
Linked responses
0 of 1
56-Day Deadline
23 May 2014
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 5 AUGUST 2013 an investigation was commenced into the death of SEBASTIAN VAUGHAN DAVIES, 23_ The investigation concluded at the end of the inquest on 25 MARCH 2014 held over two days with a The conclusion of the inquest was that the medical cause of,death was Ia Cerebral ischemia, multisystem organ failure developing bronchopneumonia and 1b Opiate excess and they gave a narrative conclusion as follows: "Sebastian died due to an excess of opiates obtained from an unknown source. We believe that procedures operated at (he Norvic Clinic could not have prevented his death"_ CIRCUMSTANCES OF THE DEATH, At the time of his death Sebastian Vaughan was a detained patient under the Mental Health Act at the Norvic Clinic On 24 July he was assessed suitable for unescorted leave under a s1 aulhority in place. On his return no illicit subslances were discovered on his person. He retired to bed at 11:0Opm_ He was unresponsive but breathing the following morning 25 July 2013. Paramedics attended and he was taken to the Norfolk and Norwich Hospital. Sadly he remained unconscious and died at the hospilal on 4 August 2013.
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
Inquest Conclusion
"Sebastian died due to an excess of opiates obtained from an unknown source. We believe that procedures operated at (he Norvic Clinic could not have prevented his death"_ CIRCUMSTANCES OF THE DEATH, At the time of his death Sebastian Vaughan was a detained patient under the Mental Health Act at the Norvic Clinic On 24 July he was assessed suitable for unescorted leave under a s1 aulhority in place. On his return no illicit subslances were discovered on his person. He retired to bed at 11:0Opm_ He was unresponsive but breathing the following morning 25 July 2013. Paramedics attended and he was taken to the Norfolk and Norwich Hospital. Sadly he remained unconscious and died at the hospilal on 4 August 2013.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.