The devastated dad of a teenage girl who died while being detained at a mental health clinic has spoken out after an inquest ruled that “inadequate care” contributed to her death.
Nadia Shah, 16, was found unresponsive in her bedroom at Elysium Healthcare’s Jasper Ward at Potters Bar, Hertfordshire, in January 2019.
The clinic provides care, treatment and support for young people who are experiencing mental health difficulties across Hertfordshire and London.
At the time, the teenage girl was detained under section 3 of the Mental Health Act 1983 and staff delayed in commencing appropriate CPR.
A 999 call was made - which was described as “chaotic” and that it “lacked focus” - with medically trained staff not being able to pass key basic information to the emergency services.
Nadia was eventually taken to hospital where she died a few days later.
Following his daughter’s death, Alkesh Shah, 58, instructed medical negligence experts at Irwin Mitchell to investigate Nadia’s care under Elysium Healthcare.
During an inquest at Hertfordshire Coroner’s Court, the jury concluded that Nadia’s death was caused by “misadventure contributed to by the inadequate care at Potters Bar Clinic” and “there was an unsatisfactory implementation of the care plan and a failure to sufficiently engage and provide cohesive care.”
Furthermore, the jury said “there was a lack of clarity around the application of the observation policy and a failure to adequately report observations to properly inform assessment of risk.”
It heard that there was “clear concern raised by the paramedics about delays to CPR” as well as “the quality and effectiveness of the CPR”, as detailed in a Root Cause Analysis Report.
An intensive care consultant advised that Nadia’s life would probably have been saved if appropriate life support was given when staff found her, as it should have been.
This should have included giving chest compressions immediately and initiating rescue breaths - either by mouth to mouth or with what is known as a ‘bag valve mask’, a device used to help a patient breathe.
There were also delays of over 13 minutes in bringing the defibrillator to the room.
The jury also heard that the Immediate Life Support training of the doctor attending the scene had expired the year before and had not been refreshed.
Catherine Knight, the specialist medical negligence lawyer at Irwin Mitchell representing Alkesh, said: “It’s been a terribly upsetting time for Alkesh, first losing his beloved daughter so tragically, but then having to relive it all again at the inquest.
“Sadly, the inquest has confirmed Alkesh’s concerns over care provided to Nadia in both the months before and hours prior to her death.
“What makes this case all the more heartbreaking is that this is not the first time that Elysium Healthcare has been the focus of investigation, and it’s vital that this time lessons are learned to improve patient safety and help prevent others from suffering similarly in the future.
“In the meantime, while there is nothing we can do to bring Nadia back, it has been an immense privilege to have helped Alkesh obtain the answers he deserves as he attempts to move forward with his life as best he can.”
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Following her Nadia’s at Elysium in 2018, there was a lack of satisfactory care provided to the teenager by clinical staff and a failure to engage with her to understand her levels of risk and how she was feeling on an ongoing basis.
In addition to failing to complete a mandatory overall risk assessment upon Nadia’s arrival, daily risk assessments were not done.
There was evidence of her having only two one-to-one psychology sessions in almost three months at Elysium, in addition to her not attending other psychology sessions on a regular basis.
On January 11, 2019, Nadia was granted leave to Alkesh’s home for one night and she returned to the Jasper Ward the following afternoon.
During a check by staff later on January 12, Nadia was found unresponsive in her bedroom.
Nadia had a pulse when she was found, which meant that her condition was survivable had appropriate CPR been commenced immediately.
However, due to delays in commencing CPR, Nadia’s brain was irreversibly damaged by the time the paramedics arrived. She was taken to hospital where she was placed in a medically induced coma and then was pronounced dead on January 15.
Her father, from East London, said: “I miss Nadia every single day and nothing will ever make up for losing her in the way I did.
“She was a kind-hearted young woman with so much to look forward to. Instead, I’ll never get to see her get married or have children of her own, and that breaks my heart.
“Nadia had completed a health and social care diploma whilst she was in hospital and had plans to qualify as a social worker.
"We even had a positive conversation about Nadia seeking apprenticeships. Her desire was to help others that had been in the same position for her and she was very much looking forward to the future.
“It’s been awful having to go through everything again at the inquest, and hear how she would probably have survived had her care plan been implemented properly, had staff engaged with her sufficiently to understand and treat her levels of risk and if CPR had been started sooner when she made this final cry for help.
“When Nadia was admitted to Jasper Ward, I was under the impression that she would be protected and well looked after.
"The job of the staff was to keep my daughter safe and I feel totally let down by what happened.”
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