Coroner urges change after death of woman at West Sussex mental health hospital

The “sudden and unexpected” death of a woman with paranoid schizophrenia in a mental health facility must lead to change, a coroner has said.

Side effects of Katherine Stamp’s medication that contributed to her death are still not fully appreciated in the NHS today, her inquest heard.

Her family spoke of the emotional heartache of waiting nearly five years for answers about her death, which they called “completely avoidable”.

Ms Stamp was found dead in 2015 at The Dene hospital in West Sussex, and an inquest into the circumstances concluded on Friday with a narrative ruling.

Over four days of evidence at Centenary House in Crawley, the coroner was told about Ms Stamp’s complex health and weight issues, but also of allegations that she was stamped on by a member of staff at The Dene.

Speaking on Friday, assistant coroner James Healy-Pratt said: “Kate died suddenly and unexpectedly.

“It was a profound shock to her family and her team of clinicians and staff.”

She had suffered with paranoid schizophrenia for more than a decade and was admitted to the hospital in 2012.

Her weight increased to the point that she was morbidly obese as a result of lack of exercise, eating, smoking, obstructive sleep apnoea and the side effects of anti-psychotic drug Clozapine, the inquest heard.

Her mother Stella Burgess told the inquest that a care assistant was prosecuted for assaulting her daughter in 2014.

Ms Burgess said: “We are heartbroken to find out one of the healthcare assistants hit Kate’s head against the floor three times and stamped on her but no-one told us.

“Kate was very unwell at the time and vulnerable.”

At the time of her death, The Dene was run by Partnerships in Care Ltd but following a corporate merger in 2016, management was assumed by the Priory Group.

Ms Stamp died from a combination of sudden cardiac arrhythmia, aspiration pneumonia, Clozapine-related hypoxia, obesity, probable obstructive sleep apnoea, smoking and schizophrenia.

Mr Healy-Pratt said staff at the hospital would have benefited from a national programme around weight management for inpatients, which would have been likely to have made a difference to Ms Stamp’s health.

He continued: “Clozapine was a complicated drug.

“Some of its side effects are underappreciated.

“These side effects may be rare but they are important. I will be writing to NHS England so that awareness is raised.”

Speaking outside the inquest, Ellie Stamp (pictured) said: “Kate was my older sister, who died at 30.

“She was like any person who had love and hope and dreams, and in her period of wellness had a house and a dog and a boyfriend and a normal life.

“This process has taken four years and eight months and has taken up pretty much all the space in my life, all the emotional space.

“We are pleased that the coroner will write to NHS England to raise awareness of the dangerous and potentially life-threatening effects of Clozapine.

“If these had been known more widely at the time or by staff at The Dene, it’s possible Kate would not have died.

“It’s scandalous that legal aid is not automatically given to families for inquests.

“These processes hold huge potential for creating system changes and preventing future deaths.

“We know now that this inquest proved that Kate’s death was completely avoidable.”

Copyright (c) PA Media Ltd. 2019, All Rights Reserved. Picture (c) Michael Drummond / PA Wire.

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