Change To The Huntercombe Group’s Observation Policy

On behalf of Attwaters Jameson Hill posted on Friday, December 2nd, 2016

Attwaters Jameson Hill represented the family of Aisha Nasiwa at the Inquest into her death, making representations to the Coroner that observations should include the checking of breathing in patients who are under observation.

Attwaters Jameson Hill Solicitors Secure A Change To The Huntercombe Group’s Observation Policy Following The Death Of A Patient.


Sadly Ms Nasiwa, who did not have a history of mental health problems and no obvious physical health problems, died from a fatal arrhythmia whilst an inpatient at the Huntercombe Hospital Roehampton.

At around 3am on 22 April 2014, Ms Nasiwa fell asleep in the lounge of the ward, woke up some time later, staggered and fell to the floor. She fell on her front and remained in the middle of the floor throughout the rest of the night. Shortly after her collapse a nurse approached her, observed that she appeared to be asleep and then walked away. Observations continued throughout the night but from a distance, with some being carried out from within the nurse’s station by looking through the window that looked out into the lounge. No one approached Ms Nasiwa again until some three hours later.

At 6.15am staff tried to wake her and had difficulty in rousing her. CPR was commenced and an ambulance called. Aisha was cold to touch when the ambulance crew arrived shortly after and remained systolic throughout. She was pronounced life extinct at 7.10am.

At the Inquest into Ms Nasiwa’s death. Dr Royston from the Huntercombe Group said that there were no national guidelines that suggested checking that a patient is breathing and further, checking that a patient is breathing whilst carrying out observations did not “sit inside my policy”. The Coroner noted that other Trusts, similar to the Huntercombe have incorporated this into their policies and this could be considered as an important part of the observation.

Dr Royston confirmed that they were “not there to monitor patient’s health” and that it was “not quite as straightforward and a balance needs to be struck between the intrusiveness and protecting a patient”.

Following the Inquest the Director of Quality and Safety for the Huntercombe Group has confirmed that where patients are known to have or be at risk of having a physical illness, they have now amended their observation policy to ensure that they have the appropriate level of physical observations as well, as far as possible and clinically appropriate, which includes that where “it is possible and clinically appropriate to assess life signs without unnecessarily disturbing the patient, a record that the patient is breathing should be made on the observation chart”.

Hopefully this new change in policy will help to prevent further deaths in the future.

Awards and Accolades

  • acn clinical negligence
  • acn conveyancing quality
  • acn family law
  • acn family law advanced
  • Lexcel
  • AVMA
  • solicitors_regulation
  • Mindful Employer
  • Resolution Specialist