According to the spouse of a woman who died as a result of excessive water consumption, she might have survived had healthcare personnel conducted adequate monitoring.
Following a breakdown, Michelle Whitehead, a "wonderful mother" of two sons, was detained in a mental health unit. She became over hydrated and entered a coma during her stay, but the staff failed to recognise this until it was too late.
A NHS trust has issued an apology to her family and acknowledged multiple shortcomings.
"Insufficient surveillance of Michelle" was one of the deficiencies at Nottinghamshire Healthcare NHS Foundation Trust; "staff were preoccupied with the use of personal mobile telephones, which was strictly prohibited on the ward," which caused distractions.
Following the presentation of evidence, the inquest jury reached the conclusion that certain deficiencies "likely contributed significantly" to her demise.
"Staff should have recognised something was gravely wrong when Michelle [apparently] fell asleep," said Michelle Whitehead, the spouse of the 45-year-old.
Michelle would have been transferred to the intensive care unit (ICU) and started on an IV had they taken action sooner. She might have been saved by that. "By the time they realised what was occurring, it was badly too late to pursue the same course of action."
His wife, according to Mr. Whitehead, was "gentle, considerate, and simple to adore."
He remarked that Michelle was outstanding and her latter days do not reflect her true self. After the couple's Down syndrome baby was born, Mrs. Whitehead quit as a neonatal nurse. She helped others full-time for 19 years.
After a mental breakdown in 2018, she was admitted to Millbrook Mental Health Unit in Sutton-in-Ashfield. She was readmitted to the unit on May 3, 2021, after her breakdown.
On the afternoon of 5 May 2021, she was observed unduly consuming water at Millbrook, according to the inquest.
Mrs. Whitehead's excessive water consumption was the result of psychogenic polydipsia, a condition that is well documented in patients with psychiatric disorders, according to the investigation into her demise.
Nonetheless, the staff at the time was unable to diagnose the condition, and she was permitted to retain unsupervised water access in her room.
Mrs. Whitehead was reportedly put to sleep after tranquillizers were administered to her to induce calmness, according to the testimony at the inquest. She eventually lost consciousness and entered a coma.
The inquest jury heard that personnel did not become aware of the situation until over four hours had passed, when a healthcare assistant observed a deviation in the patient's respiration pattern.
Later, on 7 May 2021, she passed away at King's Mill Hospital, where she had been admitted. Following this, she sustained a fatal brain injury.
Hyponatraemic encephalopathy, acute hyponatremia, and psychogenic polydipsia constituted the medical cause of her demise.
The jury reached the conclusion that the NHS trust's training system for personnel regarding rapid tranquilisation lacked "sufficient robustness" to guarantee consistent adherence to policy. Furthermore, the jury concluded that this may have significantly contributed to the demise of Mrs. Whitehead.
After the inquest, coroner Laurinda Bower sent the trust's CEO a report on preventing future deaths. She worried that "action is not taken" and more lives are lost.
The jury and coroner's verdicts are pending. We acknowledge subpar services and promise to fix the issues raised to improve patient experience.