Alert muted before teen died at unit, inquest told

Staff muted a safety alarm before a teenager was found unconscious at an NHS mental health unit, an inquest heard.

Elise Sebastian died in April 2021 after she was found unresponsive in her bedroom at the St Aubyn Centre in Colchester.

The 16-year-old was supposed to receive one-to-one care but an inquest was told an alert system, linked with her bedroom, was muted and she was left alone for 28 minutes.

The coroner was told changes had been made to the alert system.

The unit is run by the Essex Partnership University NHS Foundation Trust (EPUT), which is the subject of an ongoing public inquiry.

Elise, who was from Southminster near Maldon, was found unresponsive in her room on 17 April 2021.

She died in hospital two days later.

The alert system, called Oxyvision, was introduced in the ward two months beforehand.

The inquest was told the system was designed to help staff monitor the safety of patients in their bedrooms and bathrooms by using infrared sensors, and to reduce the number of self-harming incidents.

Essex area coroner Sonia Hayes read from a patient safety investigation conducted by EPUT following Elise's death.

It said that "confidence had been weakened" in the system because the wi-fi was not reliable on the mobile tablets used by staff.

An alarm would usually sound on the tablets if a patient was where they should not be.

The report also found an alert on a desktop computer in the nurse's office was muted.

It said this "led to a considerable reduction in the line of sight to Elise's bedroom".

The coroner was told it was the trust's policy to raise a Datix safety report if the wi-fi was not working properly, but no report could be found.

The inquest jury was told - that the day after she died - the trust changed its operating procedure, telling staff the volume on alerts must not be turned down or muted.

Laura Cozens is head of patient safety and quality at Oxyhealth, which provides the Oxyvision system.

She said the tablet software had since been tweaked, so that the volume of the alert automatically rose after 60 seconds of sounding.

The system was an "additional supportive tool and it shouldn't replace staff", she added.

Brian O'Donnell, clinical lead for EPUT, told the jury that signs had been placed around the main computer terminal asking staff not to turn down the alert volume.

He said warnings and alerts should never be ignored, adding he "would absolutely not expect any staff member to mute the volume".

Mr O'Donnell was asked if staff had muted it so they were not disturbed.

"I wasn't there, so I don't know," he added.

He admitted that since Oxyvision was installed, there had been some complacency.

"We do rely too much on technology nowadays," he said.

The inquest continues.

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