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Katherine Stamp inquest concludes

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Katherine Stamp, inquest, conclusion, anti-psychotic drug Clozapine, The Dene, Surrey and Borders NHS Trust, INQUEST“I hope the conclusions of this inquest will be followed up to ensure the same failings are not repeated.”

Katharine Stamp, known to her family as Kate, was 30 years old when she died in the care of The Dene hospital in Sussex at some point in the early hours of 26 March 2015.

The inquest held last week concluded with the coroner finding that her death was caused by a lack of oxygen in the body (hypoxia) related to the anti-psychotic drug Clozapine, causing sudden heart failure.

HM Assistant Coroner James Healy-Pratt also found several underlying physical health issues were causative factors, the effects of which could have been mitigated with effective management of Kate’s weight and relevant physical healthcare referrals.

Kate was one of three women to die at The Dene in less than a year. This is the first conclusion of the inquests into these deaths, which follow the closure of a lengthy but incomplete police investigation.

The family remain concerned that Sussex Police have still not received a number of significant documents requested for their investigation.

The Dene was a specialist hospital providing secure mental health services for women, run by the private company Partnerships in Care Ltd (PiC). Kate’s placement was commissioned by Surrey and Borders Partnership NHS Foundation Trust.

Kate was a survivor of childhood trauma and had a history of mental ill health. She was first detained under the Mental Health Act in 2001. Over the following years she spent periods in various mental health facilities and was eventually diagnosed with paranoid schizophrenia.

In her early 20s things improved and Kate enjoyed a good social life and began living independently, but in 2011 after a further traumatic incident, Kate’s mental health declined.

Kate spent time in other mental health units before being transferred to The Dene on 20 September 2012, where she was a patient detained under the Mental Health Act 1983.

Kate was treated with the antipsychotic drug Clozapine and evidence suggested that her blood Clozapine levels rose significantly prior to her death.

The inquest heard expert evidence that in the past seven years this anti-psychotic drug has been associated with an increased risk of pneumonia.

Kate had a history of coughs and serious chest infections, and twice while at The Dene had been taken to general hospital, including for double pneumonia.

The medical cause of Kate’s death was found to be Sudden Cardiac Arrhythmia (an unexpected loss of heart function), Aspiration Pneumonia, and deprivation of oxygen to the body (hypoxia) relating to Clozapine.

The coroner also found hypoxia was the result of a combination of physical health factors including Aspiration Pneumonia and probable Sleep Apnoea – linked to obesity, smoking and the effects of clozapine on her respiratory system.

Throughout her time in hospital, Kate’s family raised concerns about a lack of communication from The Dene on her mental and physical health.

Her sister Ellie told the inquest that Kate seemed very unwell in the months before her death. She noticed Kate had a sudden significant weight gain and a persistent cough, and repeatedly contacted the hospital to attempt to get Kate treatment for her physical health. However, Ellie found staff refused to listen and they did not address these concerns.

Clozapine causes weight gain in the majority of patients and is commonly used for the treatment of schizophrenia. The Dene did not monitor Kate’s recent weight gain. She had also in recent months begin experiencing symptoms of Sleep Apnoea, relating to obesity, but no referrals to diagnose or treat this had been made by The Dene.

In a narrative conclusion, the coroner highlighted the lack of any effective national weight gain monitoring programme for mental health inpatients. He concluded that effective monitoring and management of Kate’s weight, as well as a referral for specialist care of her probable Sleep Apnoea, would have mitigated the effects of her obesity, and assisted Kate’s overall physical health.

The coroner has indicated he will be making a Prevention of Future Deaths report to highlight the effects of Clozapine on physical health.

He will also be formally raising shortcomings in current coronial practice which meant the exact amount of Clozapine in Kate’s blood was not measured in the post mortem.

The coroner could not give an exact time of Kate’s death, which he estimated was between 10pm on 25 March 2015 and 2.45am on 26 March 2015, due to the fact Kate was not observed by staff at The Dene between these times.

The inquest also heard that in 2013 Kate had been assaulted by a member of staff, who was subsequently prosecuted. Her family were shocked to learn of this by chance in the following year.

An undercover Dispatches documentary at The Dene, recorded in the years after Kate’s death and broadcast in early 2018, uncovered ongoing issues with staff assaults and poor care.

Stella Burgess, Kate’s mother, said: “As a family we made every effort to do the ninety mile round trip to visit Kate in this out of area placement, and to be involved in her care as much as possible.

“This was unlike the care coordinator at Surrey and Borders Partnership NHS Trust who put her there. We were then constantly bewildered by the fact that we were not kept informed about Kate’s health by The Dene.

“I feel very strongly that Kate’s death was preventable.

“I hope now the conclusions of this inquest will be followed up to ensure the same failings are not repeated again.”

Deborah Coles, Director of INQUEST, said: “Kate was clearly failed by the systems intended to protect her long before her death.

“As were her family, who were forced to continuously battle for the care Kate needed and deserved.

“The conclusions of the inquest highlight the widespread failure of mental health services to respond to physical wellbeing and ill health, which must urgently be addressed.

“There has been repeated contentious deaths of women with serious mental ill health, assaults on patients by staff, and a long-term lack of care and support; all in a private hospital which continues to profit from services commissioned by the NHS.

“Yet so far no individual or corporate body has been held to account for the failures of Partnerships in Care, now part of the Priory Group.

“We hope the continued scrutiny and evidence of the upcoming inquests will ensure this changes.”

On 1 February 2016 Naomi Scott, 27, died in general hospital after receiving care at The Dene. The inquest into her death is due to start in the same court on 18 November 2019.

It will be followed by the inquest into the death of Susanne Roberts at The Dene on 18 October 2015, which opens on 4 December 2019.

Natasha Raghoo died at The Dene – now called Priory Hospital Burgess Hill – in 2012.

Following the inquest into Natasha’s death the Coroner made a Prevention of Future Deaths (PFD) report in March 2014, which raised issues reflected in the ongoing concerns of Kate’s family. The full PFD report and response of PiC is available here.

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