27 November 2020

Before Area Coroner for Norfolk, Yvonne Blake
Sitting at Norwich Coroners Court
23 November – 27 November 2020
 
The inquest into the death of Joanna Bailey, has today concluded with the jury finding she died from “natural causes” as a result of Sudden Unexpected Death in Epilepsy (SUDEP). Whilst the coroner refused to permit the jury to consider Joanna’s death was contributed to by neglect, the jury found that: CPR was not administered prior to emergency services arriving; there were inconsistent observations of Joanna; and that her care plan was not accessible to staff.

Joanna Bailey, 36, died on 28 April 2018 at Jessal Cawston Park hospital, where she had been detained under the Mental Health Act since October 2016. She had learning disabilities and long-standing physical health conditions including epilepsy and sleep apnoea. When Joanna was 26 she developed mental ill health, at times feeling suicidal, depressed and would hear voices.

Joanna was from Romford, and her family described her as being a loving, funny and fabulous daughter, who enjoyed listening to music, singing in karaoke competitions and going to the West End of London to see musicals. Joanna raised money for Children in Need and participated in a sponsored silence in 2017 and was organising a tombola stall just before her death. Joanna loved animals, especially her dog Milo.   

The inquest jury heard that Joanna was required to wear a sleep apnoea mask, known as a CPAP machine (continuous positive airway pressure), at night. The treatment was to help her sleep, and minimise her risk of seizures and the possibility of SUDEP. Despite the importance of her sleep apnoea mask, Joanna’s care plan failed to provide any information in relation to sleep apnoea or the use of the CPAP machine. The inquest was told that Joanna had 60 seizures in the 18 months she was detained in Jeesal Cawston Park, including at 7pm on the day before her death. However, there was no referral to an neurologist and there was no communication to the family about seizures. 

Evidence was heard from a Consultant Neurologist, who had treated Joanna previous to her admission to Cawston Park. He said that in the last 209 nights of Joanna’s life, the CPAP machine’s data chip showed that she used the machine for only 29 nights, the last being 19 January 2018. He said that the failure to ensure that Joanna regularly used her sleep apnoea mask increased her risk of SUDEP. At no point during that time did Jeesal inform Joanna’s parents that she was not using the CPAP machine, which she had regularly been using, with prompting and encouraging and assistance, since 2012.

On night shifts staff did not do 30 minute observations as directed. At 3.14am on 28 April 2018, a support worker found Joanna unresponsive in her bed. Despite a registered nurse and five care workers on duty all being trained first aiders, none of them attempted CPR. The registered nurse, who is still employed by Jeesal Group, fetched a bowl containing a pulse oximeter, a blood pressure cuff and a thermometer, but not the defibrillator that was on the ward.

The accounts provided by the staff witnesses were inconsistent and confused, painting a picture of chaos, panic and blame. Paramedics arrived at 3.32am but by that time Joanna had not been breathing for at least 18 minutes and despite their best efforts, Joanna was pronounced dead at 4.09am.
 
The Consultant Neurologist told the inquest that the failure to ensure Joanna obtained neurological treatment for her epilepsy, the lack of regular observations on the night of her death and the lack of use of her sleep apnoea mask, amounted to a failure to provide basic medical care.

In their conclusion, the jury expressed concerns regarding the following:

1. The availability of radios and communications
2. Quality of audits and spot checks
3. Quality of training and competency including regular follow ups
4. Communication, comprehension and understanding e.g. language barriers with staff and patients
5. Staff shortages
6. Communicating effectively with family
7. Training on relevant and patient specific equipment
8. Fear of blame culture stopping adequate care of patients in response to emergency situation
9. Management information
10. Relevant patient information to be accessible to all staff
11. Governance and control

During the course of the inquest, Jeesal Group’s barrister made submissions that Joanna’s father, Keith Bailey, should not be permitted to give oral evidence, as he did not have any “facts” but only “opinions” to share. When eventually Keith gave evidence, the Jeesal barrister cross-examined him for 35 minutes. Jeesal Group made submissions to the coroner that neglect should not be left to the jury, which the coroner accepted, on the basis that causation was not made out.
 
Keith Bailey, father of Joanna said: “We have listened in the last five days to a catalogue of mistakes, system problems and poor care provided by Jeesal Group to our vulnerable daughter. We desperately wanted the jury to be able to consider that our daughter’s death was contributed to by neglect because of the gross failure by the Jeesal Group to provide basic medical care. We are disappointed that the coroner refused to permit the jury to consider that Joanna died of SUDEP contributed to by neglect. We are grateful to the jury who took the time and care with the evidence and raised eleven concerns about the services of Jeesal Group which we fully endorse. We have lost our loving, funny and fabulous daughter and, in our opinion, there were so many missed opportunities to avoid her premature death.”
 
Chris Callender of Simpson Millar solicitors said: “Joanna was a highly vulnerable young woman with complex physical health needs and detained at a Jeesal Group Hospital. The inquest heard a litany of shocking individual and system failings over five days which amounted in the family’s view as a failure of care. The family are in no doubt that there were significant missed opportunities which meant that she could still be with us all today. The jury have plainly engaged with this case and found serious systemic and operational concerns within the hospital. The Care Quality Commission continue to rate the service as “requires improvement” and the family hope that lessons will be genuinely learnt.”

Deborah Coles of INQUEST said: “Joanna Bailey was let down by a damning series of failures in her care. From understaffing and shortcomings in training to a care plan which omitted reference to her sleep apnoea. That no staff even attempted CPR when Joanna was found unresponsive is chilling. Like many people with learning disabilities, Joanna’s death was avoidable.

This is a private hospital taking significant public funding and has proved itself incapable of caring for patients with complex needs. The pursuit of profit over safety has been a systemic feature of many deaths of people in the care of the state."

ENDS

NOTES TO EDITORS:

For further information and to note your interest, please contact INQUEST Communications Team 020 7263 1111 or email [email protected]. A photo of Joanna is available here.

Joanna’s family is represented by INQUEST Lawyers Group members Chris Callender of Simpson Millar Solicitors and Oliver Lewis of Doughty Street Chambers. INQUEST caseworker Bola Awogboro has been working with the family.

The other Interested Persons represented at the inquest are the Jeesal Group, a mental health nurse and a support worker.

Cawston Park was placed into special measures in September 2019, which will be kept under review. Most recent CQC report (October 2020) noted ‘further incidents where patients placed at risk of harm due to observations not being completed correctly.

An inspection in November 2018 months after Joanna died had concerns about the same issue, not enough staff to safely maintain patient observation levels. This issue had been raised at the last three inspections.

INQUEST is aware that there has been a recent death of a patient in Cawston Park also involving a CPAP machine. INQUEST’s casework team are able to provide free advice and information and we encourage the family to get in touch 020 7263 1111.