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Inquest into Electro-Convulsive Therapy

Trainee Solicitor Ronagh Craddock attended Sunderland Coroner’s Court for an inquest into the death of AB. Here she explains the case, the outcome and what happens next.


AB died on 4th April 2015 aged 71. Between 29th February 2016 and 3rd March 2016 an inquest was held before Sunderland Senior Coroner Derek Winter. The jury found that AB died as a result of a rare complication following the lawful and necessary administration of Electro-Convulsive Therapy. Ben Hoare Bell represented the deceased and her family. Also represented were Northumberland Tyne and Wear NHS Trust, Sunderland City Council and the CQC. As summarised below the Coroner issued a Regulation 28 report due to his concerns about the ineffectual functioning of the Second Opinion Appointed Doctor (SOAD) system.

Background

AB and her sister were very close. They lived together and for many years had very little social contact beyond their own company. Further to a decline in AB’s physical and mental health, and following a fall, in November 2014 she was admitted to Sunderland Royal Hospital.  There were concerns regarding self-neglect and depression.

Upon admission AB was assessed as lacking capacity in relation to her care and residence and the deprivation of her liberty was authorised under Schedule A1 Mental Capacity Act 2005.

The inquest heard evidence that during her time in hospital AB was repeatedly shouting and screaming for her sister. Numerous attempts were made by Sunderland City Council to facilitate contact but her sister was not cooperative. Although she did visit on occasion, her visits were irregular.

AB was intermittently assessed as fit for discharge for short periods from November 2014 but due to concerns over her ability to cope independently in the community, it was proposed to discharge her to residential nursing accommodation which she opposed. Court of Protection proceedings were issued by Sunderland City Council.  By early February 2015 AB’s presentation had significantly deteriorated. She continued to express anxiety about separation from her sister. On the rare occasions that her sister did visit it resulted in only a short-term improvement in her condition.

Electro-Convulsive Therapy

Despite physical care and psychiatric oversight there was no improvement in AB’s mental health. She was refusing medication and food and when she was physically strong enough she would pull out her naso-gastric tube and intravenous line.  She was suffering from malnutrition with low potassium levels which was particularly concerning to clinicians due to the potential for serious health complications including cardiac problems. Her psychiatrist concluded that it would be necessary to administer electro-convulsive therapy (ECT) as a last resort in light of this deterioration.

AB lacked capacity to consent to ECT and was therefore detained under Section 3 of the Mental Health Act. The inquest heard that in order to perform ECT on a patient lacking capacity to consent to it, a Second Opinion Appointed Doctor (SOAD) provided by the Care Quality Commission (CQC) must approve the treatment save where under Section 62 MHA it:

(a) is immediately necessary to save the patient’s life; or

(b) (not being irreversible) is immediately necessary to prevent a serious deterioration of his condition; or

(c) (not being irreversible or hazardous) is immediately necessary to alleviate serious suffering by the patient; or

(d) (not being irreversible or hazardous) is immediately necessary and represents the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself or to others.

In the case of AB, a SOAD was requested from the CQC on 24th February 2015.

The periods where AB was physically well were becoming shorter and the opportunities to engage in ECT were becoming less. It was felt by her psychiatrist that if she further deteriorated she may not be physically fit to undergo the anaesthetic required for ECT. No response was received from the CQC to the SOAD request. It later transpired that a SOAD had not been allocated due to an administrative error on the part of the CQC.

The psychiatrist therefore commenced ECT invoking Section 62 MHA.  AB received three sessions of ECT without a SOAD in place on 27th February, 6th March and 10th March 2015. The jury heard how each ECT treatment initiates an instant seizure of approximately 30 seconds. Although each of AB’s treatments appeared to go as planned, later in the day of the third treatment she went into status epilepticus, and she died in hospital 25 days later. The Pathologist concluded that the formal cause of death was anoxic-ischemic brain damage, in other words a lack of oxygen and blood to the brain.  The evidence showed that status epilepticus is an extremely rare but severe consequence of ECT, with anecdotal reports of perhaps 1 in 80,000 people developing epilepsy after treatment. The jury found that AB died as a result of this rare complication following the lawful and necessary administration of ECT.

SOAD system

The inquest heard evidence that long delays in providing SOADs were common, and that patients lacking capacity to consent to treatment are routinely undergoing several treatments of ECT prior to the attendance of a SOAD. Expert evidence was that ‘there are a significant number of incapacitous patients where almost an entire course [usually 6 to 8 sessions] of ECT has been given without the SOAD attending’. It was clear that the expectation across the mental health trust and more widely is that in these circumstances Section 62 will be used. It appeared to be almost a default positon due to SOADs not attending in time.

Coroner’s report

Coroner Winter told the inquest of his intention to compile a Regulation 28 report to prevent future deaths, which he will direct to the Secretary of State for Health. He indicated that he would wish the Secretary of State to address the timely appointment and allocation of SOADS. The coroner was concerned by evidence that a SOAD visit is achieved within 5 working days in 82% of cases and evidence that there are only a limited number of SOADs available to perform this valuable service – 105 SOADs in total across England and Wales and approximately 30-40 who carry out work in the North East. The inquest heard evidence that when a SOAD does attend, their attendance leads to a change of treatment plan in as much as 25% of cases and that in 3% of cases the treatment plan is refused.  The Coroner considered that this demonstrated the important role played by SOADs.

Once the report is made the Secretary of State must reply within 56 days and the response will be published online on the Chief Coroner’s website.


Blog by Ronagh Craddock, Trainee Solicitor

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