‘Wonderful mum’ died from drinking too much water after NHS failures

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An NHS Trust has apologised and admitted their failings to the family of a woman who died from drinking too much water in their care.

Michelle Whitehead, 45, was detained at a mental health unit in Nottingham after she suffered a breakdown.

But while she was there, she started drinking water excessively, which is known to be a symptom of patients suffering from psychiatric disorders. The excessive water consumption led Mrs. Whitehead to go into a coma, but NHS staff did not realise until it was too late.

Drinking too much water

According to the BBC, the NHS Trust admitted numerous failings and apologised to her family. The failings by Nottinghamshire Healthcare NHS Foundation Trust included “inadequate monitoring of Michelle”, as “staff were distracted by the use of their personal mobile telephones”, which was prohibited on the ward.

The 45-year-old’s husband, Michael Whitehead, told a news outlet:

“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. By the time they realised what was happening, the same course of action was far too late.”

Mr. Whitehead described his wife as “warm, caring and easy to love”.

“Michelle was an amazing person, and the last few days of her life do not represent who she was,” he said.

An inquest jury, who heard evidence, concluded some of the failings had “probably more than minimally” contributed to her death.

Mrs. Whitehead worked as a nursery nurse but gave this up when she had her son who was born with Down’s syndrome. She then became his fulltime carer for 19 years. However, Mrs. Whitehead suffered from an acute mental breakdown in 2018 and was admitted to Millbrook Mental Health Unit in Sutton-in-Ashfield.

She then suffered another breakdown in 2021 where she was admitted to the unit again on May 3, 2021.

Mr. Whitehead told the BBC:

“She essentially lost all awareness of where she was and what was happening to her. It was a total breakdown from the person she normally is.”

The inquest heard she was observed to be excessively drinking water while at Millbrook on the afternoon of May 5 2021. Meanwhile, an investigation into Mrs. Whitehead’s death found her excessive water consumption was due to psychogenic polydipsia, which is ‘well documented’ in patients with psychiatric disorders.

But because the staff failed to diagnose her with the condition at the time, she was allowed to continue having unsupervised access to water in her room.

Mrs. Whitehead was then administered with tranquilisers to calm her down, and seemingly fell asleep, the inquest was told. However, she actually became unconscious and went into a coma.

According to the BBC, the inquest jury heard staff did not realise anything was wrong until more than our hours later when a healthcare assistant noticed a change in her breathing. She was later admitted to King’s Mill Hospital, where she died on May 7 2021.

The inquest jury found, on the balance of probabilities, that Mrs. Whitehead died because she became acutely over-hydrated, leading to severely low sodium levels, causing swelling in the brain. This then caused her brain to be fatally injured.

Her medical cause of death was hyponatraemic encephalopathy, acute hyponatremia and psychogenic polydipsia.

NHS Failures

Nottinghamshire Healthcare NHS Foundation Trust admitted eight failings in relation to Mrs. Whitehead’s care in 2021.

Staff failing to adhere to the NHS trust’s policy in relation to when Mrs. Whitehead was tranquilised
Incomplete observations after she was tranquilised, meaning she was not adequately assessed at any time before concerns were raised about her breathing. This led to “missed opportunities to detect her likely deteriorating level of consciousness” and get her admitted to hospital sooner
Medical and non-medical staff not understanding the policy when a patient is thought to be asleep
A doctor discontinued observations about three and a half hours after she was tranquilised, which should not have happened until she was able to walk around again
Inadequate monitoring by staff performing observations as they “were distracted by the use of their personal mobile telephones, an activity which was prohibited on the ward”
Nursing staff failing to respond promptly to a change in her breathing, and a delay of 15 minutes to place her in the recovery position
A delay in the duty doctor arriving on scene as he did not respond promptly to mobile telephone contact from the switchboard
A 10-minute delay in letting paramedics enter the building

The inquest jury said the failure to comply with policy after Mrs. Whitehead was tranquilised – in particular by failing to monitor her consciousness level, leading to missed opportunities to detect her likely deteriorating level of consciousness and seek earlier hospital admission – had “probably more than minimally” contributed to her death.

The jury also concluded the NHS trust’s system for training staff on the use of rapid tranquilisation was not “sufficiently robust” to ensure policy was followed consistently, and this had also “probably more than minimally” contributed to Mrs. Whitehead’s death.

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.”

‘Wonderful mum’ died from drinking too much water after NHS failures

An NHS Trust has apologised and admitted their failings to the family of a woman who died from drinking too much water in their care.

NHS Failures

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