Woman, 27, died after hospital ‘ran out of oxygen’ and ‘medics used the defibrillator wrong’
Date: 2024-10-21A YOUNG woman died after a hospital ran out of oxygen while trying to save her, an inquest heard.
Florence Stewart, 27, was admitted as a voluntary patient to a mental health unit, the Campbell Centre in Milton Keynes in January.
She attempted to take her own life and died in hospital three days later.
Tom Osborne, a senior coroner for Milton Keynes, wrote she had not been monitored by staff properly, which meant she was not discovered quickly after her attempt.
Once she was found, defibrillator pads used to resuscitate her were placed on her incorrectly.
She was also given oxygen but the bottle ran out of oxygen while they tried to save her.
The Central North West London NHS Foundation Trust, which runs the site, offered its condolences to Ms Stewart’s family and said it was reviewing the case.
In a written conclusion to the inquest, which took place last week, the coroner said Ms Stewart died from “suicide whilst suffering from mental illness”.
She was detained under the Mental Health Act following an incident on January 18 when she was assaulted, the coroner said.
She attempted to take her life on January 20 and died three days later at Milton Keynes University Hospital.
She had suffered an hypoxic brain injury, which is when the brain is completely deprived of oxygen.
Following the inquest, Mr Osborne wrote a prevention of future deaths report to the NHS trust, outlining “matters giving rise to concern”.
His concerns were: “Firstly that the system of high level intermittent observations failed to prevent Florence’s suicide and needs a fundamental review.
“Secondly, that the oxygen bottle used during resuscitation ran out of oxygen.”
He said: “In my opinion action should be taken to prevent future deaths.”
The trust has until December 5 to respond to the report, detailing what action it is taking.
A spokesperson for the trust said: “While we are reviewing all aspects of this particular case, the findings of the inquest and the coroner’s comments will help us learn and make improvements to our service.
“The safety and wellbeing of our patients will always be our top priority.”
What is hypoxia?
Hypoxic brain injury happens when the brain doesn’t get enough oxygen, leading to damage or death of brain cells.
This can be caused by things like heart attacks, drowning, or breathing problems.
When the brain is starved of oxygen, the symptoms can range from mild confusion and memory problems to serious conditions like coma.
Long-term effects can include difficulties with thinking, movement, and mood, and some people may need long-term care.
Treatment focuses on getting oxygen back to the brain as quickly as possible to limit damage.
Preventing this type of injury involves managing health conditions like heart disease and practicing safety in situations where oxygen flow could be interrupted.
Source: NHS & the Cleveland Clinic
