A mother tragically died after drinking too much water when she was admitted to a mental health unit following a breakdown.
Michelle Whitehead, 45, who was described as a "wonderful mom" to two boys, first experienced an acute mental breakdown in 2018 and was admitted to Millbrook Mental Health Unit in Sutton-in-Ashfield, UK.
She had another breakdown in 2021 and was admitted back to the unit on May 3, 2021, where she died just days later after having been seen "excessively drinking water", according to an inquest.
The amount of water she consumed meant she ended up in a coma, and her husband believes she would still be alive had healthcare staff monitored her properly and intervened sooner.
According to an inquest, Michelle had been observed excessively drinking water on May 5 at the unit, with an investigation determining it was due to psychogenic polydipsia, which is well documented in patients with psychiatric disorders.
Staff failed to diagnose her with the condition and she was allowed to have unsupervised access to water in her room, before administering tranquilizers to calm her down.
After this, Michelle appeared to fall asleep but had actually slipped unconscious and went into a coma. Staff did not realize anything was wrong until over four hours had passed, when a healthcare assistant noticed her breathing had changed.
She was admitted to King's Mill Hospital where she died on May 7, 2021, with the inquest jury having found that Michelle had likely died because she was over-hydrated, which caused her sodium levels to get dangerously low, leading to swelling on the brain which ultimately caused her death.
Her cause of death was listed as hyponatraemic encephalopathy, acute hyponatremia, and psychogenic polydipsia.
The NHS trust admitted numerous failings and apologized to the family, according to reports from the BBC.
The failings noted at the inquest include the Nottinghamshire Healthcare NHS Foundation Trust's "inadequate monitoring of Michelle", as "staff were distracted by the use of their personal mobile telephones", the use of which is prohibited on the ward.
It was also stated that Michelle was not adequately assessed after she was tranquilized, which led to "missed opportunities to detect her likely deteriorating level of consciousness" and get her transferred to hospital sooner.
Nursing staff were also said to have failed to respond promptly to her change in breathing and there was a delay of 15 minutes before she was put in the recovery position, and the duty doctor did not respond promptly to the scene after being contacted by the switchboard.
The inquest jury concluded that some of the failings had "probably more than minimally" contributed to Michelle's death.
Michelle's husband Michael spoke out to say he believes she would still be alive if staff had acted sooner, saying: "When Michelle [seemingly] fell asleep, staff should have realized something was very wrong.
"Had they acted earlier Michelle would have been taken to ICU [intensive care unit] and put on a drip. That would have saved her life. By the time they realised what was happening, the same course of action was far too late."
The couple had been together since they were teenagers, and he described Michelle as "warm, caring, and easy to love," adding: "Michelle was an amazing person, and the last few days of her life do not represent who she was."
They had been together for 30 years and married for 22, and Michelle had given up work as a nursery nurse after one of their sons was born with Down's syndrome and then was a full-time carer for 19 years.
Following the inquest, coroner Laurinda Bower sent the chief executive of the trust a prevention of future deaths report warning more people could die "unless action is taken", requesting that the trust ensures staff are able to detect and manage psychogenic polydipsia.
Ifti Majid, chief executive of the trust, told the BBC in a statement: "On behalf of the trust, I once again extend our sincerest condolences and apologies to the family and friends of Michelle Whitehead for their loss.
"We are considering the findings of the jury and the coroner. We acknowledge that there were aspects of care which were not of the quality they should have been and will address the concerns raised so that the experience for patients now and in future is improved."
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