Sian Hewitt: Campbell Centre staff 'missed opportunities' to save patient

Sian Hewitt died after collapsing on a ward at the Campbell Centre

Staff at a mental health unit missed "multiple opportunities" to realise a woman had become unwell before she died, a coroner has said.

Sian Hewitt, 25, died at Milton Keynes Hospital last year after collapsing at the nearby Campbell Centre.

Coroner Tom Osborne said there was "a failure to start effective CPR".

A spokesman for the centre said changes have been made to how care is delivered.

Ms Hewitt, who had Asperger's syndrome and bipolar disorder, was admitted to the inpatient unit on 13 March 2019.

She died less than a month later on 6 April 2019 at Milton Keynes Hospital, where she was taken after collapsing on Willow Ward at the centre.

An inquest concluded she died of a pulmonary embolism, caused when a blood clot travels to the lungs.

In a Prevention of Future Deaths Report, Mr Osborne said the centre failed to carry out a risk assessment and there was a delay in administering a drug resulting in "her mania not being brought under control".

He said: "There were multiple opportunities to realise Sian had become unwell on 6 April 2019 that were missed and therefore there was a failure to start effective CPR."

His report said the "failure to recognise how seriously ill she had become" had "resulted in lost opportunities to treat her appropriately that may have prevented her death".

He said her death suggested the NHS was "unable to provide a place of safety for those who are suffering from Asperger's syndrome" or other forms of autism "when they are also suffering additional mental health problems such as bipolar".

The Campbell Centre "was not an appropriate placement" for Ms Hewitt, he added.

A spokesman for the Central and North West London NHS Foundation Trust, which runs the centre, apologised to Ms Hewitt's family for "the failings in our care provision".

He said the team had since made "a lot of changes" to how care was delivered "for patients with complex mental and physical health conditions".

Staff had also been given training on how to recognise physical deterioration and test for blood clot risks on admission.