Inadequate Care Contributed To Death Of 16-Year-Old At Elysium Healthcare’s Jasper Ward

The devastated dad of a teenager who died while being detained under the Mental Health Act has spoken out after an inquest into her death concluded.

Nadia Shah, from Cambridge, was found unresponsive in her bedroom at Elysium Healthcare’s Jasper Ward at Potters Bar in January 2019.  At the time, she was detained under section 3 of the Mental Health Act 1983.

Staff delayed in commencing appropriate CPR. A 999 call was made which was described as ‘chaotic’ and ‘lacked focus’, with medically trained staff not being able to pass key basic information to the emergency services. Nadia was eventually taken to hospital where she died a few days later.

Dad instructs Medical Negligence lawyers to investigate daughter's death

Following his daughter’s death, Alkesh Shah, 58, instructed medical negligence experts at Irwin Mitchell to investigate Nadia’s care under Elysium Healthcare.

Alkesh has now spoken out after an inquest into Nadia’s death at Hertfordshire Coroner’s Court. The jury concluded that Nadia’s death was caused by “misadventure contributed to by the inadequate care at Potters Bar Clinic” and “there was an unsatisfactory implementation of the care plan and a failure to sufficiently engage and provide cohesive care.”

Furthermore “there was a lack of clarity around the application of the observation policy and a failure to adequately report observations to properly inform assessment of risk.”

Also, “the emergency and resuscitation response was lacking and CPR was not carried out promptly by the clinic staff.”

Inquest jury hears concerns about 'delays to CPR'

It heard that there was “clear concern raised by the paramedics about delays to CPR” as well as “the quality and effectiveness of the CPR”, as detailed in a Root Cause Analysis Report. Expert evidence was heard from Dr Danbury, an Intensive Care Consultant, who advised that Nadia’s life would probably have been saved if appropriate life support was given when staff found her, as it should have been. This should have included giving chest compressions immediately and initiating rescue breaths (either by mouth to mouth or with what is known as a ‘bag valve mask’, a device used to help a patient breathe).  There were also delays of over 13 minutes in bringing the defibrillator to the room.

The staff working at Elysium Healthcare, including nurses and a doctor, should have been able to adequately and promptly provide these standard life support procedures in a secure mental health unit, but despite training, they were unable to do so. The jury also heard that the Immediate Life Support training of the doctor attending the scene had expired the year before and had not been refreshed.

Expert Opinion

“It’s been a terribly upsetting time for Alkesh, first losing his beloved daughter so tragically, but then having to relive it all again at the inquest.

Sadly, the inquest has confirmed Alkesh’s concerns over care provided to Nadia in both the months before and hours prior to her death.

What makes this case all the more heartbreaking is that this is not the first time that Elysium Healthcare has been the focus of investigation, and it’s vital that this time lessons are learned to improve patient safety and help prevent others from suffering similarly in the future.

In the meantime, while there is nothing we can do to bring Nadia back, it has been an immense privilege to have helped Alkesh obtain the answers he deserves as he attempts to move forward with his life as best he can.”
Catherine Knight - Associate Solicitor

Teenager detained under Mental Health Act admitted to Elysium Healthcare Jasper's Ward

Nadia had been known to the Child and Adolescent Mental Health Services since March 2017.  She had previously been detained under the Mental Health Act prior to her admission to Elysium Healthcare’s Jasper Ward on 23 October 2018; where she remained under section. She appealed this in the week before her death, but the tribunal were not able to lift her section as there were no beds at any appropriate step down facilities for Nadia to be discharged to.

Following her arrival at Elysium, there was a lack of satisfactory care provided to Nadia by clinical staff and a failure to engage with her to understand her levels of risk and how she was feeling on an ongoing basis. In addition to a failure to complete a mandatory overall risk assessment upon Nadia’s arrival at Elysium, daily risk assessments were not done. There was evidence of her having only two one-to-one psychology sessions in almost three months at Elysium, in addition to her not attending other psychology sessions on a regular basis. There were a number of instances in Nadia’s notes where she told staff she was feeling very low or ‘rock bottom’ and this was not acted upon.

On 11, January 2019, Nadia was granted leave to Alkesh’s home for one night.  She returned to the Jasper Ward the following afternoon.

Girl, 16, found unresponsive

During a check by staff later on 12 January, Nadia was found unresponsive in her bedroom.

The jury also heard that there was confusion amongst staff as to what the frequency of observation checks on Nadia should be.  Although hospital directors stated that the policy was four times an hour, many staff including those clinically responsible for Nadia were under the impression, and had directed, that the checks should be every 15 minutes at most. The gap between Nadia’s previous check and when she was found was 19 minutes.

Nadia had a pulse when she was found, which meant that her condition was survivable had appropriate CPR been commenced immediately, Dr Danbury advised. However, due to unacceptable delays in commencing CPR, Nadia’s brain was irreversibly damaged by the time the paramedics arrived. She was taken to hospital where she was placed in a medically induced coma.  She was pronounced dead on 15 January.

Dad speaks out following inquest conclusion

Alkesh, from East London, said: “I miss Nadia every single day and nothing will ever make up for losing her in the way I did.

“She was a kind-hearted young woman with so much to look forward to.  Instead, I’ll never get to see her get married or have children of her own, and that breaks my heart.

“Nadia had completed a health and social care diploma whilst she was in hospital and had plans to qualify as a social worker. We even had a positive conversation about Nadia seeking apprenticeships. Her desire was to help others that had been in the same position for her and she was very much looking forward to the future.

“It’s been awful having to go through everything again at the inquest, and hear how she would probably have survived had her care plan been implemented properly, had staff engaged with her sufficiently to understand and treat her levels of risk and if CPR had been started sooner when she made this final cry for help. 

“When Nadia was admitted to Jasper Ward, I was under the impression that she would be protected and well looked after.  The job of the staff was to keep my daughter safe and I feel totally let down by what happened.

“Things could have turned out so differently that day, and while nothing will ever bring Nadia back to me, all I hope for now is that something is learned from my tragedy.  I wouldn’t want anyone else to go through what I have.”

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