A coroner is demanding answers from the Secretary of State for Health Jeremy Hunt after hearing how a woman died when bungling hospital staff thought she was faking a COMA.
Depressed Michelle Jannetta, 21, took an overdose in a cry for help – but not enough of the painkillers to prove lethal if the correct medical procedures had been followed.
But her blood samples were mixed up with another patient, notes were scribbled on surgical gloves and she was wrongly allowed to sleep on her back.
Michelle’s family said they were now pursuing a claim for medical negligence against the hospital where she died.
The 21 year-old was rushed to the A&E department at Milton Keynes Hospital, Bucks at midnight on March 7 by concerned friends.
Initially she showed no signs of an overdose and refused to tell nurses she’d taken anything before admitting taking an overdose of Tramadol.
She was kept in overnight for observation but medical staff mixed up her blood samples with those of another patient.
As a result no traces of the drug were found and staff assumed she was faking her condition when she had in fact slipped into a coma.
Medical notes were scribbled on the back of plastic SURGICAL GLOVES and failed to show the dangerously high saturation levels.
The inquest at Milton Keynes heard that Michelle from Bletchley was put on her back to sleep – obstructing her breathing and contributing to her death.
Nurses also admitted to hearing her snoring – a known symptom of a Tramadol overdose – but she was given no antidote and died at 11am the day after being admitted.
Tom Osborne, the coroner for Milton Keynes, voiced concerns that unqualified staff could still be putting patients at risk all over the country.
He said he would be writing to both the Hospital Trust and Secretary of State, Jeremy Hunt, with a Rule 43 ruling.
That requires a written response within 56 days addressing what measures will be put in place to prevent similar failings in the future.
Recording a narrative verdict, Mr Osborne said: “There was a failure to undertake and report on her regular observations and a failure to recognise her deteriorating condition or the seriousness of her situation.
“That resulted in a lost opportunity to render further effective treatment before she went into respiratory arrest caused by obstruction of her airway.”
After the inquest Michelle’s family said they were pursuing a claim of clinical negligence against Milton Keynes Hospital NHS Foundation Trust.
Her sister Nicola Rose said: “We adored her and will never forget her.
“She should have been monitored closely.
“She was a frequent visitor to the hospital and we think they definitely disregarded her visits as if she was an inconvenience to them.
“I believe they thought she was time-wasting.
“It is a small consolation to us that in reporting the problems she hasn’t died in vain.
“If it helps people across the country then that is a benefit without a doubt.
“We hope her death changes attitudes towards mental health patients in hospitals.”
Martin Wetherill, medical director at Milton Keynes Hospital, said: “Our thoughts are with Michelle’s family at this difficult time.
“We have put together an action plan following our investigation, which has now been delivered.
“We will be continuing to improve our service in regard to emergency patients and ensuring lessons are learned.”
It also emerged that the Crown Prosecution Service carried out their own investigations into the level of care afforded to Michelle.
It was revealed that Michelle was only checked TWICE despite being at the hospital for ELEVEN HOURS, the solicitor for her family claims.
Carolyn Lowe, clinical negligence partner at Henmans Freeth law firm, also claimed vital time was wasted when checks should have been carried out because medics thought Michelle was faking her condition.
But because no one individual could be held responsible it meant that no charge of gross negligence could be brought forward, the lawyer said.
Ms Lowe said: “I can only hope that the family can take some comfort from knowing that as a direct result of Michelle’s death the Coroner has written to the Secretary of State for Health asking him to consider changing hospital policy so that observations taken in patients who are seriously ill, like Michelle, are to be carried out by trained nurses.
“As the Coroner said, this should mean that Michelle has not died in vain.”