Inquest touching the death of SS – We acted in an inquest for the family of a woman who sadly died while subject to a section under the Mental Health Act. She died from a pulmonary embolism whilst under section at Hellesdon Hospital and totally dependent on staff for her care. Following a ten day inquest, the jury returned a critical Art 2 narrative verdict against the Trust, finding multiple failings by the Trust possibly causative of death. This was a case where at the outset a Coroner had provisionally ruled that Art 2 did not apply and this was a ‘natural causes’ death.

This provisional ruling was overturned at an interim hearing and following the inquest the jury recorded in their conclusion that ‘there were a number of collective failings and missed opportunities that may have contributed to [SS’s] death.’ Failure to carry out VTE assessments, complete clinical notes properly and lack of training were all identified as possible causative factors. The Coroner also determined that she would issue a ‘Prevention of Future Deaths’ report to the Trust regarding the failure by medical staff to follow policies about when they should carry out risk assessments and the quality of their clinical and nursing notes.

Fatima Jichi of Garden Court was instructed.