A 41-year-old man died of a heart attack in Mile End Hospital after nurses assumed he was just 'holding his breath'. CPR compressions were then wrongly given to his tummy instead of his chest, rendering them completely ineffective, a Prevention of Future Deaths report has found. Gary Ottway died from a heart attack on 21 April 2021 which was bought on by psychological stress, while he was admitted to Mile End Hospital mental health facility.
At the time of his death, he was detained alone in a seclusion room where he was supposed to be under constant surveillance. When nurses observing Mr Ottoway noted that he wasn't breathing, they did not immediately enter the seclusion room, because they deemed that "unsafe" following his earlier violent behaviour, the report, published today reads.
The coroner, M Hassell, wrote: "The senior duty nurse told me at inquest that he could not be sure that Mr Ottway was not holding his breath, though he had never done this and there was no evidence that he was doing so now. The senior duty nurse also told me that the visibility through the Perspex panel was poor, though he had never brought this to anyone’s attention and did not do so after Mr Ottway’s death."
Various steps further delayed attempts to resuscitate Mr Ottoway - including a nurse failing to call the rapid response team immediately, instead taking "a couple of minutes" to call another nurse and the duty doctor first. A junior doctor was last to be called, but by the time he arrived on the scene neither of the other two professionals had yet entered the room to assess Mr Ottoway.
By then, it had been at least seven minutes since nurses spotted he wasn't breathing, well outside the three to four minute window of opportunity for resuscitation without inevitable brain damage or death. The emergency "grab bag" had also not been retrieved, which then took another 30 seconds. The junior doctor said they were not properly trained to fully deal with the resuscitation.
The coroner said: "The junior (and only) doctor called to assist in the attempted resuscitation was not familiar with the contents of the emergency grab bag. [They] told me that it would not have occurred to him to ask for any equipment to assist with ventilation other than a pocketmask, and explained that he was not trained in giving adrenaline or any other medicines for resuscitation."
A pocket mask is a device used to safely deliver rescue breaths during a cardiac arrest or respiratory arrest. "As he was the only medical resource available in the case of an emergency, these seem significant gaps," the coroner added.
When paramedics arrived, they found that chest compressions were being given by nursing staff to Mr Ottway’s abdomen instead of his chest, rendering them ineffective, the coroner said. The friends of Mr Ottotway, set up a GoFundMe in the wake pf his death, describing him as "big hearted" and "always a shoulder to cry on".
The message reads: "Gary had such a tough life from such a young age being bought up in children's homes and finally Foster care where he was helped with his reading & writing, learning the rights & wrongs of life. He wouldn't want much in return just to be fed, watered and a place to sleep! He always gave a shoulder to cry on.
"Gary was never a materialistic person just loved everyone & had such an impact on everyone's lives. If he wasn't doing carpentry, mixing music on his decks then you would see him practising his wing chun martial arts for hours on end! As with many people during this horrific Covid-19 pandemic Gary's mental health & wellbeing started to suffer and sadly over the last few months took a spiral out of control.
"Being in his one bedroom bedsit day in & day out on his own not being able to see the people he loved & cared about took it's toll on him. Unfortunately the last week of his life he ended up spending in a mental health unit trying to get everything under control & rebuilding his life".
The coroner addressed the report to East London NHS Trust Fundation Trust, who manage Mile End Hospital, in order to identify the failings, in an attempt to prevent future deaths.
MyLondon has contacted East London NHS Foundation Trust for comment.
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