Oxygen 'ran out' at Milton Keynes mental health facility, contributing to woman's death

A coroner’s report has highlighted critical failings in resuscitation efforts and monitoring at the Campbell Centre in Milton Keynes

A coroner’s report has highlighted critical failings in resuscitation efforts and monitoring at the Campbell Centre in Milton Keynes
Author: Cameron GreenPublished 14th Oct 2024

A recent coroner's report has highlighted critical issues during the resuscitation efforts following the suicide attempt of a 27-year-old woman at the Campbell Centre in Milton Keynes. The report, issued by Senior Coroner Tom Osborne, focuses on the case of Florence Elizabeth Catherine Stewart, who died after her attempt on January 20, 2024.

The report reveals that during the emergency response, the oxygen bottle used ran out, which significantly hindered the medical efforts to save Stewart’s life. Despite attempts to resuscitate her, she later died on January 23, 2024, at Milton Keynes University Hospital.

The inquest, which concluded on October 9, 2024, also found that Stewart had been admitted to the Campbell Centre after being assaulted on January 18, 2024, and was supposed to be monitored with high-level intermittent observations. However, these observations were not carried out effectively.

“During the investigation, it became clear that the system of high-level intermittent observations failed to prevent Florence’s suicide and needs a fundamental review,” Osborne stated.

The coroner expressed concern that similar incidents could occur in the future if action is not taken. “In my opinion, action should be taken to prevent future deaths,” he said.

The Central North West London NHS Foundation Trust has been asked to respond to the report within 56 days, outlining measures to improve patient safety at the Campbell Centre.

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