Nurses' neglect led to death of psychiatric patient

Dean Bray suffered acute heart failure at Antelope House

A patient at an NHS psychiatric unit died after nurses failed to respond to his breathing difficulties for more than 10 hours, a coroner has said.

Dean Bray, 47, died from acute heart failure on 29 December 2021, while he was in a seclusion room on Hamtun ward at Antelope House in Southampton.

An inquest jury concluded the nurses' "gross failures" and neglect led to his death.

The unit was run at the time by Southern Health, now Hampshire and Isle of Wight Healthcare NHS Foundation Trust, which said it was working on issues raised by the coroner.

Mr Bray's health began to deteriorate at about 21:45 GMT on 28 December, Hampshire coroner Rachel Spearing said.

She said nurses failed to "adequately act upon and escalate Dean’s high respiratory rate" until 08:00 the following day.

In a narrative conclusion, the inquest jury recorded: "There was a gross failure to escalate Dean’s deteriorating physical presentations... based on inadequate monitoring of Dean’s physical health and a lack of recognition of Dean’s medical emergency.

"On the balance of probabilities, but for the gross failures, Dean’s life probably could have been prolonged."

In a Prevention of Future Deaths report, the coroner said she was concerned that paramedics were delayed in reaching Mr Bray because they were not informed of the best route to the ward.

She added that there was no outside phone line to make a 999 call from the seclusion room.

In a statement, the NHS trust said: “We offer our deepest sympathies to Dean Bray’s family and loved ones.

"We are committed to addressing the concerns raised during the inquest and to continuously improving patient safety.

"We will now provide a detailed response to the coroner, outlining the actions we are taking and when they will be completed.”