'Series of failures' led to mental health patient's death

Thursday 19 September 2019

Two nurses' complete failure to carry out observation checks on a young and vulnerable woman being held on a mental health ward was just 'one hole' in the 'Swiss cheese' of errors which led to her death, according to an expert witness giving evidence before Guernsey's Royal Court.

Dr Geraldine O'Sullivan, a Consultant Psychiatrist with 40 years experience and the director of a UK healthcare trust, was speaking as a defence witness in the ongoing manslaughter trial.

Rory McDermott, 32, and Naomi Prestidge, 31, are both facing one count of manslaughter through gross negligence. This charge arose after it was discovered that they had failed to complete 15-minute observation checks for nearly two hours when caring for Lauren Ellis, 22. 

Lauren, who had emotionally unstable personality disorder, was supposedly known to the ward, and it was written across the front of her medical notes that she was a 'ligature risk' - a person at risk of trying to tie something around their neck to strangle themselves. Ms Ellis was also known to have severely self harmed. 

After attending the Emergency Department at the PEH, she admitted herself to the Oberlands Centre on 11 October, 2017, because she had been harming herself in a dangerous way, but during the early hours of the next day she was found dead.

Mr McDermott and Ms Prestidge, the Crown Prosecution say, were negligent in their care of Ms Ellis, and that led to her death.

"Non-compliance [with observation checks] was endemic in the ward," - Dr O'Sullivan. 

Pictured: Both nurses are facing a charge of manslaughter through gross negligence, because they failed to carry out observation checks assigned to them, and then falsified records after the fact. 

The defence started to present its case to the court yesterday, which seemed to look to deflect responsibility from the two nurses.

Dr O'Sullivan, who worked on a 'root-cause report' of the death, told the Court that there had been a lack of risk assessments, and no care plan in place to help staff so they could know what Lauren needed.

She also said it was endemic on the ward that staff did "not see the point" of observation checks, and therefore wouldn't do them - she backed that up by saying she did not believe a check every 15 minutes would realistically help prevent someone from self harming if they were determined to do so. Finally, she said there was poor communication between staff, which led to some knowing what was going on, and others not being as aware of the sitauation. 

All of these matters, she suggested, were better placed in front of the Nursing & Midwifery Council to be professionally sanctioned, rather than the criminal courts. 

But Prosecutor Advocate Chris Dunford retorted saying none of this would have mattered if Mr McDermott and Ms Prestidge were not going to do their observation checks anyway. They had been sat in the nurses station using their mobile phones.

Dr O'Sullivan concluded that it was too simplistic a view to blame Ms Ellis' death on one thing, but said there were a whole series of failures. 

To read more about the Prosecution case, and how Mr McDermott said Ms Ellis needed a "line of ket" among other allegations, click here. 

More to come...