Roxanne Brown - known as ‘Roxy’ - collapsed and died on 2nd November 2019 from a pulmonary embolus caused by a deep vein thrombosis in her right leg. At the time of her death, she was detained under section 3 of the Mental Health Act in a mental health hospital. Despite having been obviously unwell for days – and repeatedly showing abnormal vital signs – nursing staff failed to escalate her care or send her to A&E.

After a 2 week inquest at Surrey Coroner’s Court, the jury found that from 28th October 2019 there was a failure by the hospital staff to follow mandatory guidelines resulting in ‘inadequate care and a failure to escalate’. There were ‘several missed opportunities for Miss Brown’s care and treatment to be escalated, including transfer to A&E’. On the evening of 2nd November 2019, Roxy collapsed. Although CPR was given by staff, she could not be resuscitated and sadly passed away. The jury found that the death was contributed to by neglect.

Ms Johnson, our client’s mother said that: “I feel vindicated knowing what I have always known, that the State failed my daughter whilst she was a vulnerable woman in their care”
The Coroner will be issuing a Prevention of Future Deaths (PFD) report to the Nursing and Midwifery Council (NMC) regarding the training and standards of registered mental health nurses as per the findings of the jury. Ms Johnson welcomes this and hopes that this prevents other families from going what she has had to go through in the future.
Tessa Hutchinson represented Ms Johnson, assisted by Keiu Kikas. Matthew Turner of Doughty Street Chambers was instructed.
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