Evidence
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Date of report: 12/08/2024
Ref: 2024-0444
Deceased name: Nimo Osman
Coroner name: Ian Potter
Coroner Area: Inner North London
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: East London NHS Foundation Trust
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THIS REPORT IS BEING SENT TO:
1. [REDACTED] Chief Executive Officer East London NHS Foundation Trust |
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1 | CORONER
I am Ian Potter, assistant coroner, for the coroner area of Inner North London. |
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2 | CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
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3 | INVESTIGATION and INQUEST
On 3 May 2022, an investigation was commenced into the death of NIMO OSMAN, then aged 30 years. The investigation concluded at the end of an inquest with a jury, heard by me between 1 July 2024 and 5 July 2024. The inquest concluded with a short-form conclusion of natural causes. The medical cause of death was: 1a hypoxic ischaemic brain injury (unknown aetiology) II pulmonary thrombo-embolism, pneumonia, schizophrenia |
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4 | CIRCUMSTANCES OF DEATH
At the time of her death on 23 April 2022, Nimo Osman was in state detention because she was subject to a Hospital Order (in accordance with sections 37 and 41 of the Mental Health Act 1983). Ms Osman was admitted to Rosebank Ward (a psychiatric intensive care unit) at the Tower Hamlets Centre for Mental Health, which is on the Mile End Hospital site, on 5 April 2022. The |
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5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- (1) Following the discovery of Ms Osman’s collapse on Rosebank Ward (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. 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. (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. |
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6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that you have the power to take such action. |
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7 | ![]() You are under a duty to respond to this report within 56 days of the date of the report, namely by 7 October 2024. I, the coroner, may extend the period. |
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8 | ![]() I have sent a copy of my report to the Chief Coroner and to the following: |
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9 | ![]() HM Assistant Coroner, Inner North London 12 August 2024 |
The post Nimo Osman: Prevention of Future Deaths Report appeared first on Courts and Tribunals Judiciary.
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