“The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic…”

The coroner’s concerns

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— The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the ri ive medication especially if not using it and the desirability of oximetry director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine, of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit. P| consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring. There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian. It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation. Neither hospital has addressed how this dialogue is to be instigated when required, nor how these risks should be addressed; reliance on GP advice seeming to be insufficient. 2 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the Trust has the power to take such action.

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, 2015-0381

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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