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Area Coroner issues Prevention of Future Deaths report following death of a psychiatric inpatient at Wotton Lawn Hospital


Severine Kelly died after choking on a sandwich at Wotton Lawn Hospital on 1 October 2022.  Following a jury inquest, which investigated the circumstances of Severine’s death, Area Coroner Roland Wooderson found there was a risk that future deaths could occur unless action was taken by Gloucestershire Health & Care NHS Trust.  The Coroner issued a Prevention of Future Deaths report to the Trust’s Chief Executive outlining six areas of concern relating to out of date staff medical training, the need to update risk assessments after medical emergencies, staff knowledge as to when an ambulance should be called in a medical emergency, the availability of a portable phone for staff to speak to 999, the importance of meeting paramedics at the hospital entrance to avoid delay and ensuring defibrillators were correctly calibrated.

Sophie Beesley, instructed by Yvonne Kestler at Leigh Day, represented Severine’s mother and sister.

Click here to read more about this case (via the Leigh Day website).

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Sophie Beesley

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