An anorexic teenager under 24-hour hospital supervision died in bed - in front of nurses who thought she had just fallen asleep. Rachael Stubbs, 17,was on the highest level supervision and should have had her hands and neck in full view of nurses at all times at the private Cheadle Royal Hospital, in Cheadle, Greater Manchester, an inquest heard. A coroner is now writing to health bosses, saying observations 'were not carried out properly'.Source: Daily Mail
The teenager went to bed face down and began to make heavy breathing noises 'like she was hyperventilating', on January 13, 2008. Nurses, who should have been within arm's reach of Rachael at all times, did not intervene and 15 minutes later the noises stopped, but they assumed she had fallen asleep. Nurses on the Meadows Unit dialled 999*; when they realised she was not breathing 10 minutes later
Stockport deputy coroner Joanne Kearsley said: 'I find from the evidence that the (level four) observations were not being carried out correctly. I accept that this was a particularly difficult time for the unit and the staff who have to deal with distressing and difficult patients and situations, but I fail to find any reason why the guidance was not followed. Perhaps of most concern was the fact that CPR was not commenced when Rachael was found. I would expect all staff to be reminded of the importance of this in an emergency situation.'
* WTF? Aren't nurses supposed to know CPR? Isn't that a bit like the fire brigade calling the fire brigade?