Research points to gross deficiencies in the care of women who drank too much water
An inquest jury has found there were “gross deficiencies in care amounting to neglect” before a woman suffered a heart attack in a private psychiatric hospital due to complications from drinking excessive amounts of water.
Lillian Lucas, 28, known to her family and friends as Lily, died in September 2022 after being found unconscious in her room in the Milton ward of Cygnet Hospital in Kewstoke, near Weston-super-Mare, where she had been since June had been recorded. .
An inquest jury at Avon Coroner’s Court ruled on Wednesday that staff had missed opportunities to provide care that could have prevented Lucas’ death, including a failure to monitor her deteriorating condition and an inadequate response to her decline.
Lucas, who lived in Malmesbury, Wiltshire, was a mental health nurse who had previously been diagnosed with schizophrenia and had been admitted to various hospitals numerous times in the years before her death, the inquest heard.
On September 8, 2022, she was found unconscious in her room after drinking excessive amounts of water and taken to Bristol Royal Infirmary (BRI), the jury heard. She died the next day.
Post-mortem examination revealed that she died of a heart attack and the effects of psychogenic polydipsia, when a person experiences an uncontrollable urge to drink water due to a mental disorder.
The jury concluded on Wednesday that there were “gross deficiencies in her care that amounted to neglect”. In the inquest report, the jury said the Milton department was “understaffed at a level considered unsafe.”
The jury said: “It was observed that Lily was drinking excessively from around midday (on September 7, 2022) and efforts by staff to restrain her were inadequate. Lily’s mental and physical health deteriorated over the afternoon, with staff failing to document Lily’s condition as per hospital policy.
“There was a failure to recognize the … psychogenic polydipsia and that persistent excessive drinking could result in serious injury or death. Neither urgent nor adequate medical attention was provided or sought in accordance with Cygnet policy. Throughout the afternoon, it was not possible to adequately monitor her deteriorating mental and physical condition, including her vomiting and defecation in both her room and communal areas.
“Despite 15 minutes of evidence and visual observations, there was insufficient response and concern about Lily’s continued presentation. Physical observations were not made until later in the evening. Opportunities were missed to provide care that could have prevented Lily’s death.”
Coroner Dr Peter Harrowing said he had decided not to submit a report to prevent future deaths as he was satisfied Cygnet had taken steps to address concerns raised, including about staffing levels.
A doctor who had treated Lucas before her admission to Cygnet spoke during the eight-day study about possible reasons why someone would drink excessive amounts of water. Dr. James McIntyre, a consultant psychiatrist, said psychogenic polydipsia could be caused by the side effects of antipsychotic medication or as a symptom of the psychosis itself.
On September 5, as Lucas’ condition deteriorated, she was prescribed clozapine, the inquest heard. “Lily had always feared being prescribed clozapine,” Lucas’ mother, Mary Curran, said in her statement. “Lily was aware of the possibility of serious side effects.”
Lucas’ father, Paul, visited on September 5 and expressed concerns to medical staff about the “severity of the risk” of side effects, the inquest heard. A doctor told him the benefits outweighed the risks and assurances were given that his daughter would be monitored, the jury was told.
On the opening day of the inquest, Curran read out a pen portrait of her daughter, who graduated from the University of the West of England in 2017 as a mental health nurse.
“Lily was beautiful, loving, generous and hilarious,” she said. ‘She was so carefree and fun, and so full of mischief. One of her nursing colleagues described her as a fierce and progressive mental health nurse. Lily knew what good nursing care and support looked like.”
A Cygnet spokesperson said: “We take our responsibilities to provide safe care very seriously and where lessons need to be learned, we want to share, implement and embed them.
“We recognize that improvements were needed and have since implemented a number of changes to ensure the delivery of timely, safe, person-centred care. Ensuring safe staffing levels is a priority and in addition to changes to our hospital management, we have increased staffing levels across the service and reduced our use of agency and bank staff to ensure continuity of care.”
They added: “All nursing staff at Cygnet Hospital in Kewstoke have undergone additional training and we have employed a full-time physical health manager who works across the hospital to improve the skills of our staff team and provide support with important physical health monitoring where necessary. ”