During an inquest, it was revealed that a staff alarm was active for nearly an hour when a patient was found unresponsive at the Derwent Centre, a mental health unit in Essex. The incident involved 18-year-old Morgan-Rose Hart, who was discovered in her bedroom in 2022 and tragically passed away a week later.
Details emerged during the inquest at Essex coroner’s court, where it was disclosed that Morgan-Rose had informed staff that she intended to take a shower. The mental health unit employed a digital patient monitoring system by Oxehealth, which triggered an audible alert on staff tablets if a patient spent more than three minutes in the bathroom, according to the BBC.
The inquest heard that the emergency warning persisted for over 52 minutes after Morgan-Rose had communicated her plan to use the shower. The alert, marked by a “red box” on the display screen and an audible sound, was expected to prompt staff to check on the patient in person before deactivating the warning.
Concerns were raised during the proceedings about “alert fatigue,” with suggestions made to prevent the lowering of device alert volumes. The Oxehealth system indicated that alerts had been “interacted” with five times—where staff could view a camera image of the patient’s room—before someone eventually checked on Morgan-Rose.
Nurse Vera Green expressed devastation over the incident, citing reliance on the Oxehealth system, which continued to indicate that the patient was in her room despite the optical sensor technology being in use.
Marina Laing, a nurse and clinical matron at Essex Partnership University NHS Foundation Trust (EPUT), disclosed that the implementation and initial training on the Oxehealth system occurred online and not in person.
Morgan-Rose was found unresponsive on July 6, 2022, and passed away at Princess Alexandra Hospital in Harlow a week later. The ongoing inquest, conducted in front of a jury, is exploring the circumstances surrounding this tragic incident.