Oxygen ran out during life-saving attempt on woman

Florence Stewart, 27, was a patient at the Campbell Centre in Milton Keynes

An oxygen bottle ran out while staff at a mental health unit were attempting to resuscitate a woman, an inquest found.

Florence Stewart, 27, was admitted as a voluntary patient to the Campbell Centre in Milton Keynes in January. She attempted to take her life and died in hospital three days later.

Senior coroner for Milton Keynes, Tom Osborne, wrote she had not been observed properly, causing a delay in detecting her attempt, and defibrillator pads were also incorrectly placed on 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 narrative 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 18 January when she was assaulted, the coroner said.

She attempted to take her life on 20 January and died three days later at Milton Keynes University Hospital. She had suffered an hypoxic brain injury.

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 5 December 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."