The 39-Year-Old, Father-Of-One, Died While Sectioned Under The Mental Health Act

The widow of a former soldier is calling for lessons to be learnt after a jury inquest found that there were failures in the hours before his death while he was sectioned under the Mental Health Care Act at Ward Oak 2 Cavell Centre, Peterborough.

Nepal-born Prem Rai, 39, was a Ghurkha soldier for 18 years before embarking on a career change and training as a butler. However, during his training Prem was admitted to Chelsea and Westminster Hospital and referred to mental health services in July 2016.

Over the following weeks, Prem was kept under medical observation at Ward Oak 2 Cavell Centre, Peterborough. On the morning of 19 August, 2016, Prem was found unresponsive in his bed with no obvious sign of the cause of his death.

Following Prem’s death, his widow Chandra Rai instructed medical negligence lawyers to investigate the care Prem was given by the Cambridgeshire and Peterborough NHS Foundation Trust.

An inquest into his death was held at Peterborough Town Hall, where the jury found there that there were failures in the manner in which observations were performed prior to Prem being found unresponsive shortly before 9am on 19 August.

The jury also found that it is probable that Prem had died several hours prior to his recorded time of death due to the fact that rigor mortis was present when his death was confirmed by the paramedic at 09:12 on 19th August.

Over the course of the inquest, the findings of a Serious Incident Investigation Report, conducted by Cambridgeshire and Peterborough NHS Foundation Trust in the wake of Prem’s death, were heard.

The report concluded that the senior management team at Cavell Centre needed to develop mechanisms to ‘have a greater oversight of the conduct of the core clinical tasks and governance of the ward’. The report identified a number of influencing factors:

• Lack of adherence to guidelines, policies and procedures
• Lack of evidence of communication between staff
• Environmental disruption

Gurpreet Lalli, a specialist medical negligence solicitor at Irwin Mitchell’s Cambridge office representing Chandra, said:

Expert Opinion

“This is a sad case and, over a year later, Chandra is still trying to come to terms with the loss of her husband and her child’s father.

“Chandra has been awaiting the outcome of the inquest for a long time and she, along with the family, is relieved to have some answers at last. It has been their wish that lessons can be learned from Prem’s death.

“The family will always believe that earlier identification of distress by staff at the Cavell Centre could have prolonged, or even saved, Prem’s life by transferring him to Peterborough City Hospital for emergency treatment.

“The Serious Incident Report and Inquest have revealed some areas of concern and we hope that these will be addressed as soon as possible to improve patient safety.” Gurpreet Lalli - Senior Associate Solicitor

The inquest heard that the family were concerned about:

• The apparent failure to ensure that all of those who cared for Mr Rai were aware of his ongoing health issues, and subsequent consequences of mismanaged
• Whether Prem should have been on 1:1 observations in the hours leading up to his death rather than 15-minute observations
• The apparent failures at the Cavell Centre to perform and document observations properly in the morning on 19 August 2016, in the hours leading up to and following Prem’s death
• The apparent failure to intervene in the hours prior to Prem’s death in response to likely signs that he was in distress as his pulmonary haemorrhage developed and the issue of not transferring him to the nearby Emergency Department at the Peterborough City Hospital.

Chandra, who has a nine-year-old son with Prem, said: “While myself and the family hope that lessons can be learned from the issues which have been highlighted to ensure that other lives can be spared, Nothing can bring my husband and my son’s father back.

“It will forever be a source of great distress that, if things had been done differently, Prem’s death could have potentially been prevented.

“I do not want any other family to suffer like we have suffered or like my husband suffered.”

Background

In July 2016, Prem was living in London while training to become a butler following 18 years’ service in the armed forces as a Ghurkha soldier. He was admitted to Chelsea and Westminster Hospital following difficulties speaking.

He remained in Chelsea and Westminster Hospital until 21 July, at which point he was admitted to the Cavell Centre, Peterborough, under Section 2 of the Mental Health Act. Prem remained at the centre until his death on 19 August 2016.

While he was under the care of the Cambridgeshire and Peterborough NHS Foundation Trust Prem suffered with a number of health issues, including a possible stroke, seizures and urinary incontinence.

On 16 August, the health professionals took the decision to detain Prem under Section 3 of the Mental Health Care Act. This was due to his Section 2 admission expiring on the 17 August.

When this was explained to Chandra, she expressed concerns due to the issues she had seen Prem face since his admission to the centre, including a recent fall which had left Prem with swelling around his right eye.

Despite wanting to take Prem into private care, the decision was made to keep Prem at the centre and to put him under one to one observation.

In the early hours of 19 August, Prem was noted to have been awake around 1am and then again between 6am and 7am. He was also noted to have been asleep every 15 minutes between 7:15am and 8:45am.

At approximately 8:55am, staff entered Prem’s room to give him his medication and breakfast. Laid on his bed, Prem did not respond to his name being called. When a pulse could not be found, staff started CPR and called for paramedics, but this was unsuccessful.