“Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took…”

The coroner’s concerns

(1) Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half and hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events. I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital. I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future. However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future. (2) I heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). I was taken through the detailed ‘Action Plan’ that was devised as a result of the various ‘service delivery problems’ (SDP), ‘care delivery problems’ (CDP), and ‘additional lessons learned’ (ALL) that were identified as a result of the SI Report. Not all of the SDPs, CDPs or ALLs are of such seriousness that I consider that they create a risk of future deaths unless action is taken. However, some of them do, in my opinion, reach that threshold. While the evidence of Nurse A and the accompanying Action Plan did provide prima facie reassurance that action has been taken, the evidence of Nurse B (who, as previously stated is relatively senior and experienced) has significantly undermined what I heard from Nurse A. The undermining of that evidence and reassurance from Nurse A, leads me to conclude that there is, at the very least, a realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist. For this reason, I consider that further reassurance is required in relation to the following matters of concern: (a) CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients. (b) CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients. (3) With regard to the East London NHS Foundation Trust’s policy in relation to Venous Thromboembolism, I noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines in some respects. There also appeared to be aspects of the policy that were ambiguous and open to different interpretations. I was told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at 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, 2024-0444

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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