On 11 November 2013 I commenced an investigation into the death of Christopher Ricardo WILLIAMS, then aged 50. The investigation concluded at the end of the inquest on 7 March 2014. The conclusion of the inquest was Natural Causes and the medical cause of death was Massive Pulmonary Embolism.

(1) At the time of his death Christopher was detained under Section 37 of the Mental Health Act 1983. He was resident at Adams Ward, St Mary’s Hospital, Warrington, Cheshire. Adams Ward is a medium secure unit.

(2) On 5 November 2013 Christopher complained of shortness of breath during the previous few days. He had a past medical history of pulmonary tuberculosis. He was seen by the GP the same day. The GP diagnosed a chest infection and prescribed antibiotics.

(3) Christopher was subject to Level 1 observations (every 30 minutes). Throughout the night, up to and including the check at 5.30 am on 6 November 2013, Christopher appeared to be sleeping in his bed, giving no cause for concern. At 6 am he was found to be out of bed, kneeling on the floor against the bed. He appeared to be ‘snoring’ but was unresponsive. An ambulance was called.

(4) A defibrillator machine was brought from an adjacent ward. The defibrillator did not work. Staff changed the battery pack but the defibrillator still did not work.

(5) A second defibrillator machine was sent for but by the time it had arrived the ambulance paramedics were already at the scene.

(6) Christopher was pronounced dead at the scene at approximately 6.30 am. 2