Hospital’s ‘gross failure’ contributed to patient’s death
Posted 03 December 2024 - 11:00
An urgent need for stronger safety protocols has been highlighted after a patient's death is linked to nursing staff's medication errors at a London hospital
A hospital has been told to urgently address safety risks after a patient died following administration of an anti-psychotic drug by a nurse without national guidelines being followed.
Mental health patient Yemisi Cielto-Opaleye was found dead by nursing staff at St Pancras Hospital in London in December 2023, just hours after she was given an Olanzapine injection. Ms Cielto-Opaleye had developed a rare complication from the drug, which is used in the treatment of symptoms of schizophrenia.
But the medicine was prescribed to her without the mandated consent of two doctors, and staff failed to carry out vital signs checks following its administration.
After an inquest last month, assistant coroner Edwin Buckett sent a prevention of future deaths report to North London Mental Health Partnership, which runs the hospital, stating several concerns and citing ‘a gross failure’ by the trust to provide basic medical attention, which needs to be addressed to prevent further deaths from occurring.
The inquest jury reached a narrative verdict and concluded that Ms Cielto-Opaleye had died from the toxic effects of the drug and that neglect had contributed to her death.
Following Ms Cielto-Opaleye’s admission to the hospital’s Sapphire Ward a decision had been made to introduce Olanzapine to her treatment. She was given the drug orally for three to four days, before moving to administering it by depot injection. However, this goes against the recommended two-week oral trial period for Olanzapine before it is given by injection, and contributed to its toxicity.
Justification for giving the drug fell below standards set out in the Mental Health Act, inquest finds
The jury also found the justification for giving the drug also fell below the standards of section 62 of the Mental Health Act, as it was neither ‘lifesaving or reversible’. The requirement to have a second independent doctor sign off the prescription was also not met.
Ms Cielto-Opaleye received her first injection of the drug on 13 November 2023, and although she failed to cooperate with vital signs checks she appeared to have no adverse side effects.
A month later, a plan was in place for one of the nurses on Sapphire Ward, who had completed the Olanzapine training, to both prepare and administer the injection and, in line with policy regarding the drug, conduct a first set of vital signs checks as well as being available for the duration of the three-hour post-injection observation.
However, the investigation found that this did not happen. The preparation, administration, monitoring and witnessing of the injection and checks were divided among multiple healthcare staff members ‘resulting in inadequate levels of oversight’.
The coroner’s report stated: ‘Following the injection, there was a total lack of clarity around responsibility and delegation of post-injection checks, where the nurse in charge failed to allocate tasks consistent with safe implementation of the plan.
Coroner cites gross failure to provide basic medical attention
‘Communication was inadequate and no staff member on Sapphire Ward was clear on their responsibility to conduct post-injection checks that day. As a result, none of the vital signs checks stipulated in the trust’s Olanzapine policy were carried out, representing a gross failure to provide basic medical attention to Yemisi (Ms Cielto-Opaleye).’
The inquest heard how Ms Cielto-Opaleye was checked only once after receiving the injection, when a member of staff observed her by looking through the door of her room.
Three hours after being given the injection she was found face down on the floor in her room by the nurse in charge and CPR was carried out and an ambulance called. However, she was later pronounced dead by ambulance staff at 6.45pm that day.
Coroner Mr Buckett told the trust that in future patients must be made aware of the risk of death when using an Olanzapine injection and, unless a qualified member of staff had capacity to monitor a patient, then an injection should not be given.
Trust apologises and says it has revised prescribing protocols to ensure safe practice
The trust has until 17 January 2025 to respond to the prevention of future deaths report issued by the coroner. A trust spokesperson said: ‘The trust would like to apologise unreservedly to the family of Ms Cielto-Opaleye for her death while she was in our care. To address the issues identified, we have revised the Olanzapine prescribing protocol to ensure safe practice.
‘Additionally, we are implementing a dedicated improvement programme to strengthen practices related to the management of in-patient services, including efficient shift coordination, safe and effective handovers, and improving the observation and engagement of patients. This builds on our ongoing efforts to enhance safety and reflects our commitment to preventing such incidents from happening again.’
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