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Jean-Yves Gilg

Editor, Solicitors Journal

Mental health: Preventing tragic outcomes

Mental health: Preventing tragic outcomes


There needs to be a more collaborative approach between medical units to protect patients with both physical and mental health issues, says Hannah Travis

In 2012, a month after the birth of her child, Alice Gibson-Watt, 34, was restrained by emergency services in response to an episode of severe postpartum psychosis at her London home.

Alice was later transferred to the Lakeside Mental Health Unit in West Middlesex Hospital, where she suffered a cardiac arrest. An inquest recently concluded that Alice died from a brain injury caused by cardiac arrest. The use of restraint was found not to have contributed. There had, however, been gross failures surrounding her resuscitation, which led to her brain injury.

The inquest concluded that Alice would have survived if CPR was given promptly and effectively. Alice’s inquest has raised concerns about treatment of physical conditions in a mental health setting.

Alice’s case will strike a chord with many. She was a new mother, with no previous mental health concerns. Postpartum psychosis can appear out of the blue in women with no previous history of mental illness. If acted upon quickly it can be treated, otherwise symptoms can escalate drastically, which can result in serious consequences.

Symptoms vary from woman to woman but they will often experience delusions or hallucinations coupled with depression, mania, or confusion.

So how did postpartum psychosis lead to Alice’s untimely death? The most distressing conclusion of the inquest is that Alice’s death was avoidable. The inquest found that there was a distinct lack of basic care provisions available in the mental health unit.

Why should Alice’s care for her physical injuries have been responded to any differently because she was in a mental health setting? Basic CPR training and robust emergency procedures should surely be standard for all medical staff where they are responsible for patient wellbeing.

The inquest found that it took nearly 25 minutes to begin CPR and the crash team then had difficulty accessing the mental health ward due to the entrance being locked and no member of staff being available to allow them entry. This would not be acceptable in A&E or any other ward, so why was it allowed to happen here?

Mental health units need to have staff with sufficient training in identifying and treating the physical needs of patients, not just mental health conditions. The trust has taken a welcome step towards identifying failures and making positive changes to avoid instances where this could happen again.

The trust acknowledged that: ‘Increasingly our patients have complex mental and physical healthcare needs and it is essential that our care and treatment responds to both.’

Examples of such improvements could include dedicated training in key healthcare skills, better record keeping, and having an appointed nurse responsible for responding to emergency situations such as cardiac arrests. There needs to be a collaborative approach with other units to ensure an immediate response is available.

More needs to be done to prevent tragic outcomes such as in Alice’s case. Knowledge is key.

Hannah Travis is a medical negligence solicitor at Bolt Burdon Kemp