“The safety of the resuscitation process where detained under MH section”

The coroner’s concerns

1. The safety of the resuscitation process where detained under MH section. 2. The lack of identification of the risks of deterioration and death of a patient chronically on Clozapine with query obstruction, who may benefit from escalation or further investigation, in the emergency department of the acute hospital. CORONER’S MATTERS OF CONCERN are described as follows: 1. The delays in accessing advanced life support (ALS) resuscitation in the MH  hospital were worse than expected in the community.  London Ambulance Service  target for Category 1 calls is 7 minutes and yet it took 37 minutes before the  paramedics arrived. Despite concerns that resuscitation skills were hard to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially  no IV line could be found, then none could be inserted. 25 minutes of asystole  elapsed before Adrenaline was administered. Evidence was heard that MH Trusts  cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in  patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the  Resuscitation Council has apparently approved the Trust policy. Thus, the safety of  a patient detained by the State, who has a cardio-respiratory arrest, would seem to  vary according to post code, some sites not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer  psychosis have increased risks of premature death, including suicide and  cardiovascular deaths, in part related to treatment, the State would seem to have a  responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site  where there is co-location of acute services and whether units with high  concentration of detained psychotics should and can be safely equipped to provide  Advanced Life Support. 2. The acute Trust has taken a number of steps to facilitate identifying the risks of a  patient who is referred with suspected obstruction. Outstanding is the development  with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction, including pseudo-obstruction (a complication of  Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics.  There is currently no national formal guideline on management of bowel  obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be  given to the development of a guideline, which might identify the use of red flags to  escalate and investigate those at most risk.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0470

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0