A mum tragically died after drinking too much water, suffering a devastating brain injury that saw her fall unconscious and into a coma.
Mum-of-two Michelle Whitehead was admitted to Millbrook Mental Health Unit in Sutton-in-Ashfield, Nottinghamshire, in May 2021, having been detained following a breakdown.
However, just two days later, she tragically died after becoming ‘acutely’ over-hydrated.
Whitehead’s medical cause of death was confirmed to be hyponatraemic encephalopathy, acute hyponatremia and psychogenic polydipsia, with Nottinghamshire Healthcare NHS Foundation Trust admitting several failings that contributed to her death.
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Ifti Majid, chief executive of the trust, said in a statement to the BBC: "On behalf of the trust, I once again extend our sincerest condolences and apologies to the family and friends of Michelle Whitehead for their loss.
"We are considering the findings of the jury and the coroner. We acknowledge that there were aspects of care which were not of the quality they should have been and will address the concerns raised so that the experience for patients now and in future is improved."
An inquest was told that the cause of Whitehead’s brain injury was ‘on the balance of probability’ because of an ‘acute over-hydration of water, leading to severely low sodium levels, causing swelling in the brain’.
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In the hours before her death, 45-year-old Whitehead was given a lower dose of diazepam than required, and drank water excessively.
Her consciousness level was also not assessed at any time after she was given lorazepam.
The inquest heard how there had been a delay in the duty doctor arriving on the scene, a 10-minute delay in admitting the paramedics to the building and a 15-minute delay in Whitehead being placed in the recovery position.
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A staff nurse observed Whitehead’s excessive consumption of water, which she had unsupervised access to in her room.
The jury also found the trust’s admitted failure to comply with its rapid tranquilisation policy - in particular, by failing to monitor her consciousness level - led to missed opportunities to detect any deteriorating level of consciousness.
Whitehead’s husband Michael, 45, told the BBC: "When Michelle [seemingly] fell asleep, staff should have realised something was very wrong.
"Had they acted earlier Michelle would have been taken to ICU [intensive care unit] and put on a drip. That would have saved her life.
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"By the time they realised what was happening, the same course of action was far too late."
He described his wife as ‘warm, caring and easy to love’, adding: "Michelle was an amazing person, and the last few days of her life do not represent who she was.”
Jess Hardiman