November 24th 2023.
The death of Michelle Whitehead, 45, has caused a catalogue of errors by the Nottinghamshire Healthcare NHS Foundation Trust to be flagged.
Married mother-of-two, Michelle, was admitted to the Millbrook Mental Health Unit in Sutton-in-Ashfield, Nottinghamshire, on May 3, 2021. Just days later, she was found unconscious and was admitted to King’s Mill Hospital next door where she later died.
At the inquest, it was heard that Michelle had sustained a non-survivable brain injury on May 5, which was most probably caused by ‘acute over-hydration of water, leading to severely low sodium levels, causing swelling in the brain’. The jury also found that serious mistakes and failings had been made by the NHS. These included a delay in the duty doctor arriving on the scene, a 10-minute delay in admitting the paramedics to the building, and a delay of 15 minutes in her being placed into the recovery position.
The jury also noted that Michelle had been given a lower dose of diazepam than she needed and that her consciousness level was not assessed after she was given sleeping pills. Furthermore, only one observation was made by the staff nurse supervising her that day, and Michelle also had unsupervised access to water in her room.
The inquest reached a narrative conclusion citing the NHS’s failure to monitor Michelle’s consciousness level which had led to missed opportunities to detect her deterioration and seek earlier hospital admission.
In a statement from Michelle’s husband, Michael Whitehead, and his family following the inquest, they expressed their gratitude to the coroner and their legal council, and thanked the jury. They said: ‘This has been a very difficult process, and the way it has been handled by all involved has returned Michelle her dignity and given us a measure of comfort. We miss Michelle very much and will love her forever.’
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