A 'gorgeous' woman died after nurses delayed CPR thinking she was faking unconsciousness.
Edwige Nsilu, 20, was found with multiple ligatures at Colne Ward, St Andrews Healthcare in Essex where she had been sectioned, an inquest heard.
An inquest at Essex Coroner's Court heard how multiple failures including not updating her care plan, not increasing observation intervals, and delays to giving life support, played a role in her death.
The daughter of Democratic Republic of Congo immigrants was first taken into care at the age of 15 and detained under the Mental Health Act at 16, after which she was detained in multiple secure units until her death.
She was diagnosed with emotionally unstable personality disorder and had a history of self-harm.
She was transferred to Colne Ward on April 8 2019, which the court heard was difficult and led to incidents of self-harm and aggression like tying ligatures and punching herself in the face.
But the jury heard she was motivated to get home to her family, and engaged with therapy between August and December 2019.
It meant she was given unescorted leave around Christmas and New Year in December 2019, but when she returned in January 2020 she got worse, reports My London.
There were multiple ligature incidents which resulted in an increasing level of 15 minute observations on January 13 2020. But her care plan was not updated from January 7 2020 and remained unchanged despite the increased risk.
The self-harm continued and Edwige was put in seclusion after punching herself, tying a ligature, and becoming aggressive to staff. There was a medical emergency on January 23 when she tied a ligature and lost consciousness, followed by two more ligatures on January 26 and 27.
On February 2 it was discovered she had given things to another patient for self harm, and despite expressing remorse was found with another ligature that night.
The court heard how the hospital's plan to manage her self-harm remained the same and there was no record of any discussion or review about whether the observations should be increased.
The night before her death Edwige slept for 13 hours, but there was no review by a doctor of her mental state.
The healthcare assistant responsible for Edwige recorded her observations until 3:30pm, when she was called off the ward to deal with another incident.
She said she would have handed over responsibility for the observations, but no nurse accepted they had taken them over.
The inquest heard Edwige was found by a senior nurse at 3:55pm with three ligatures. He removed two ligatures by hand and used cutters and needed the help of another nurse to remove the third.
The nurse who found Edwige told the court they initially thought she was "feigning unconsciousness" as a means of luring staff before attacking them, despite no evidence this had happened before.
Instead of starting CPR the first nurse left Edwige with the second nurse to find an oximeter to measure her pulse, only for the second nurse to leave for another incident.
They tried the oximeter and a blood pressure machine, but failed to get readings for both. The inquest heard evidence from an expert paramedic, who made clear there was no reasonable justification for the nurses' actions.
A medical emergency was called at 4:03pm and a physical healthcare assistant arrived on the ward at 4:05pm and initiated CPR. An ambulance was called at 4:08pm by the third nurse, which took her to intensive care at Basildon University Hospital. On February 5 doctors told the family Edwige had an irrecoverable hypoxic brain injury, so they chose to end her life support that day.
Edwige’s mum, Joyce Nsilu said: "We loved Edwige very much. She was loving, warm, nurturing, gorgeous and strong. We called her the mother of all children because she had a deep love for every single person. Every day feels like a dream because she was such a blessing to our family, but I know that one day, with God ’s grace, we will see her again.
"Edwige will always be our daughter, big sister, and aunt. She never got to meet her nieces and nephews, but we will always remind them and future ones of who she was. We miss her dearly and will never stop wondering what could have been different. Rest my child and know that mummy loves you too forever."
Joseph Morgan, solicitor for the family, said: "The jury's conclusion is utterly damning. St Andrews failed in their most basic duty to ensure Edwige's safety. The evidence heard during this inquest about the multitude of failures in Edwige’s care has been harrowing and shocking. It paints a picture of a unit that was unsafe for patients, with tragic consequences for Edwige.
"This case highlights many of the reoccurring systemic failures within inpatient mental health care, including a failure to appreciate the seriousness of self-harm attempts, overwhelmed staff ill-equipped to care for vulnerable patients, a lack of leadership and oversight. These failures are endemic in a system bursting at the seams and putting the most vulnerable patients at risk."
Failures at Colne Ward identified by jury
- Inadequate design and completion of observation forms
- Insufficient interaction with patients when carrying out observations
- Inadequate updates of Edwige’s care plan after 8 January 2020
- Failure to increase Edwige’s observation intervals despite recent escalation of serious incidents relating to Edwidge’s behaviour and deterioration of Edwige’s mental health
- Inadequate record keeping
- Serious delay in declaring a medical emergency for Edwige
- Unacceptable delay in delivering basic and immediate life support for Edwige
- Unacceptable delay in notifying emergency services.
Colne Ward has now closed after an independent investigation was ordered. A St Andrews Healthcare Essex spokesperson said: "We want to extend our deepest condolences to Edwige’s family and friends for their loss. We fully accept the outcome of the inquest and we will use the findings to ensure lessons are learnt so we can prevent anything like this from happening again.
