Essex mental health patient died despite staff alarm - inquest
- Published
Morgan-Rose Hart died six days after an incident at the Derwent Centre in Harlow
A staff alarm was active for almost an hour during an incident in which a patient was found unresponsive at a mental health unit, an inquest heard.
Morgan-Rose Hart, 18, was found in her bedroom at the Derwent Centre in Essex in 2022 and died a week later.
An inquest has heard how she told staff she was going to take a shower.
An audible alert is triggered on the staff digital tablets when a patient has been in their bathroom for longer than three minutes, the jury was told.
Staff members at the Essex Partnership University NHS Foundation Trust (EPUT), which runs the unit in Harlow, and the head of patient safety at Oxehealth - which runs the digital patient monitoring system - gave evidence at Essex coroner's court on Monday.
The court heard the emergency warning was active for more than 52 minutes after Ms Hart had already said she was going to use the shower.
The alert triggers a "red box" on the alarm display screen and an audible alert is sounded. The inquest heard the audible alarm switches off, but staff are still warned that a patient is in the bathroom.
Ms Hart's mother described her as "caring and funny"
Area coroner Sonia Hayes was told when the alert was sounded, staff were expected to go to the patient's room to check on them before turning the warning off.
The inquest discussed how there were concerns over "alert fatigue", with one person suggesting in an Oxehealth meeting that volume buttons should be "glued" to prevent device alerts being turned down.
It was explained that alerts on the Oxehealth system were "interacted" with five times - whereby staff can view a camera image of the patient's bedroom - before someone eventually checked on Ms Hart.
Online training
Marina Laing, a nurse and clinical matron at EPUT, said the implementation and initial training on the Oxehealth system took place online and not in person.
Ms Hart was found unresponsive in her bedroom on 6 July 2022 and died at Princess Alexandra Hospital in Harlow a week later.
Her mother has described her as "caring and funny, with a huge passion for animals and wildlife".
The inquest, which takes place in front of a jury, continues.
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- Published7 November 2023
