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Patient died from choking on a sandwich after failings at mental health hospital in Gloucestershire delayed emergency response, inquest finds

Failings at Wotton Lawn Hospital in Gloucester delayed the emergency response to a 41-year-old woman who died after choking on a sandwich, an inquest has found.

Posted on 28 February 2024

Gloucester Coroner’s Court heard that Severine Kelly from Cheltenham died after eating a sandwich whilst alone in her bedroom at the hospital on 1 October 2022.

Once staff realised Severine was choking, they attempted to remove the blockage in her airway and resuscitate her. Arrival of another staff member at Wotton Lawn was delayed by a faulty alarm system and arrival of specialist emergency responders was delayed by 24 minutes after they initially went to the wrong ward. Severine was treated at the scene by a doctor and paramedics who were unable to save her. 

Severine suffered from schizoaffective disorder and had been detained under the Mental Health Act since 2017. She was transferred to Wotton Lawn Hospital in October 2021 and was being cared for in the hospital’s Greyfriars Psychiatric Intensive Care Unit. 

Picture of Severine Kelly
Picture of Severine Kelly


Recording a narrative conclusion, the inquest jury highlighted the following failings, which did not cause Severine's death, but which were admitted by the hospital trust investigator and other witnesses: 

  • Staff needed to be aware of the need to update risk assessments and take appropriate action following a medical event that could cause harm to a patient. Specifically, Severine suffered a similar choking incident in 2021 which was described by a senior medical professional at the inquest as a "missed opportunity". 
  • A paramedic attending Wotton Lawn hospital was unsure which ward he should attend due to lack of guidance from staff at the hospital. This led to a delay in the paramedic attending Severine. 
  • The alarm system at the time of Severine's death did not immediately direct medical staff to the location of the emergency i.e. Severine's bedroom. 

The Area Coroner, Roland Wooderson, found there was a risk that future deaths could occur unless action is taken by Gloucestershire Health & Care NHS Foundation Trust. He issued a Prevention of Future Deaths report to its Chief Executive outlining the following concerns:  

  • The medical training of some "bank" (temporary) staff, at the hospital on 1 October 2022, was not up to date. 
  • Staff needed to be aware of the need to update risk assessments and take appropriate action following a medical emergency. Specifically, Severine’s previous choking incident in 2021. 
  • A doctor, attempting to assist Severine and speak to the 999-emergency service had to leave the patient to use a mobile phone due to a poor signal. He did not have access to a portable landline telephone which would have meant that he could have stayed with the patient. 
  • A paramedic was unsure which ward he should attend due to lack of guidance from staff at the hospital. This led to a delay in the paramedic reaching Severine. 
  • There seemed to be uncertainty at which stage of a medical emergency a medical professional should call the ambulance service. 
  • A defibrillator used on the 1 October 2022 appeared not to have a working internal clock. 

The trust has until 18 April 2024 to respond to the Prevention of Future Deaths report. 

Severine’s family were represented at the inquest by solicitor Yvonne Kestler from Leigh Day and counsel Sophie Beesley of Old Square Chambers.

The family have been supported by the charity INQUEST.

Severine’s sister, Alison Kelly said: 

“When Severine passed away I lost my much loved, intelligent and artistic sister. For her to die at the hospital responsible for her care from something as simple as eating a sandwich has been incredibly hard for us to comprehend. During the inquest we have heard about a series of failings during the incident in which she died. However, we were pleased to hear hospital staff who gave evidence being open and honest about these failings. We now hope that the coroner’s recommendations will result in positive change at the hospital.” 

Severine’s mother Mrs Kelly said: 

“My beautiful, talented daughter lost her life at the hospital which was entrusted with her care. Sadly, our grief has been compounded by hearing about failures during the attempts to save her life. Nothing can ever make up for the loss we feel as a family and we sincerely hope the hospital takes action to ensure no other family has to endure what we have been through.” 

Leigh Day solicitor Yvonne Kestler said:  

“It is now clear that there were failings at Wotton Lawn Hospital which delayed the emergency response to Severine’s choking incident. Of great concern is evidence there was a previous similar incident less than a year earlier, which members of staff were not aware of, and the trust had not picked up in its own investigation. This was recognised as a “missed opportunity” by the jury and the coroner. The family are grateful that these issues came to light during the inquest process and for the coroner’s recommendations.” 

Selen Cavcav, senior caseworker at INQUEST said:  

“There were a catalogue of failures at Wotton Lawn Hospital during the incident in which Severine died. At INQUEST, we’ve seen too many preventable deaths involving choking, yet lessons are not being learned. We’re calling for a National Oversight Mechanism to ensure that when failings are identified, recommendations are followed up on, and lives can be saved.” 

Yvonne Kestler
Abuse Actions against the police Human rights Judicial review

Yvonne Kestler

Yvonne Kestler is a senior associate solicitor in the human rights department.

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