During an incident at a mental health unit in Essex in 2022, a staff alarm remained active for nearly an hour when a patient, 18-year-old Morgan-Rose Hart, was discovered unresponsive in her room at the Derwent Centre. Ms. Hart had informed staff that she intended to take a shower.
According to the testimony presented at the inquest held at Essex Coroner’s Court, an audible alert is activated on staff digital tablets if a patient spends more than three minutes in their bathroom. The emergency warning persisted for over 52 minutes after Ms. Hart had already communicated her intention to use the shower.
Representatives from the Essex Partnership University NHS Foundation Trust (EPUT), responsible for the unit in Harlow, and the head of patient safety at Oxehealth, the entity operating the digital patient monitoring system, provided evidence during the hearing.
The court learned that the alert, which displays as a “red box” on the alarm screen accompanied by an audible signal, ceases after a while. However, staff members continue to be notified that a patient is in the bathroom. When the alert sounds, staff are expected to visit the patient’s room to verify their well-being before deactivating the warning.
The inquest raised concerns about “alert fatigue,” with discussions on preventing device alerts from being turned down, such as the suggestion to “glue” volume buttons, occurring in Oxehealth meetings.
Notably, the Oxehealth system’s alerts, which allow staff to view a camera image of the patient’s room, were “interacted” with five times before someone eventually checked on Ms. Hart.
A statement from nurse Vera Green expressed devastation over the incident, emphasizing reliance on the Oxehealth system, which continued to indicate that Ms. Hart was in her room despite the critical situation.
Marina Laing, a nurse and clinical matron at EPUT, revealed that the implementation and initial training for the Oxehealth system occurred online rather than in person.
Ms. Hart was discovered unresponsive on July 6, 2022, in her bedroom and passed away a week later at Princess Alexandra Hospital in Harlow. Described by her mother as “caring and funny, with a huge passion for animals and wildlife,” the inquest, held before a jury, is ongoing.