The Bethlem patient died at Croydon University Hospital after becoming constipated and unintentionally inhaling the contents of his own stomach
A coroner has said that the death of a man sectioned at Bethlem Royal Hospital raises questions as to whether high risk patients should get to choose where they are treated.
Luke Chatterton died on December 11, 2023 at Croydon University Hospital after becoming constipated and inhaling the contents of his own stomach due to vomiting. Mr Chatterton—who was sectioned at Bethlem, in Beckenham, with treatment resistant psychosis—had a long history of constipation related to the psychiatric medication Clozapine which he was prescribed.
The coroner highlighted the lack of guidelines for hospital staff around the management of bowel obstructions which could have alerted them to the risks. He also said if Mr Chatterton had been detained at a mental health unit that was close to an acute hospital, he may have got the appropriate advanced life support resuscitation to give him a better chance of survival.
According to a prevention of future deaths report written by Assistant Coroner Professor Andrew Harris, Mr Chatterton began vomiting and was in “great pain” on the morning of his death. Bethlem referred him to Croydon with suspected intestinal obstruction most likely caused by constipation related to Clozapine. At Croydon’s A&E department, Mr Chatterton was x-rayed but no escalation for professional advice nor CT scan were sought and he was discharged, arriving back at Bethlem around 2pm.
A surgical review of the x-ray results later identified that his bowels showed signs of impending obstruction and a risk of perforation. Mr Chatterton’s pain worsened once back at the psychiatric hospital, and eventually he vomited and collapsed unconscious. CPR was carried out while an ambulance was called, but there was a 37-minute delay in paramedics arriving. Fluids and adrenaline were administered after Mr Chatterton had flatlined for 25 minutes.
His heart activity was restored and he was taken back to Croydon’s A&E department at 7.45pm. Mr Chatterton died after further resuscitation at 8.51pm. Professor Harris identified two matters of concern in his report, the first of which relates to the safety of the resuscitation process carried out at Bethlem.
A right to choose
He stated that delays in accessing advanced life support resuscitation at Bethlem “were worse than expected in the community”. Evidence was heard at the inquest into Mr Chatterton’s death that mental health trusts such as Bethlem cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site.
In his report, Professor Harris said: “The safety of a patient detained by the state, who has a cardio-respiratory arrest, would seem to vary according to post code, some sites not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the state would seem to have a responsibility to mitigate these risks, when compulsorily detaining them.
“It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide advanced life support.”
Professor Harris raised this concern both with the South London & Maudsley NHS Trust (which operates Bethlem) and with the Secretary of State for Health and Social Care, Wes Streeting.
No guidelines to help A&E staff spot issue
The second matter of concern raised by Professor Harris was in relation to Croydon’s emergency department failing to identify the risk of death posed by a patient chronically on Clozapine with a potential bowel obstruction. He said that Croydon University Hospital Trust had since taken a number of steps to facilitate identifying such risks, but that Croydon along with Bethlem had not yet developed educational guidelines to aid in similar situations in the future.
Professor Harris wrote: “There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk.”
The coroner brought this concern to the attention of Croydon University Hospital Trust as well as the Medicines and Healthcare Products Regulatory Agency, the Royal College of Psychiatrists and the Royal College of Emergency Medicine.
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