Mother died after drinking too much water in mental health hospital while NHS staff were ‘distracted by their mobile phones’, coroner says

• Michelle Whitehead was detained at Millbrook hospital in Nottinghamshire
• She ended up over-hydrated, leading to low sodium levels causing brain swelling

A mother died after drinking too much water at a mental health hospital where a coroner said staff failed to adequately monitor her as they were ‘distracted’ on their phones.

Michelle Whitehead’s husband said she would still be alive today if her carers had observed her properly.

She was detained at Millbrook hospital in Sutton-in-Ashfield, Nottinghamshire, in 2021 displaying symptoms of paranoia, irritability, agitation and reality distortion, an inquest heard. The ‘wonderful mum’ of two boys started drinking water excessively and went into a coma – but staff did not realise this until it was too late.

In a prevention of future deaths report, coroner Laurinda Bower outlined numerous failings admitted by Nottinghamshire Healthcare NHS Foundation Trust, including ‘inadequate monitoring’ as staff were ‘distracted by the use of their personal mobile phones’, even though it was prohibited on wards. In the report sent to the trust last month, Ms Bower said she was concerned more people could die ‘unless action is taken’.

She said Mrs Whitehead, 45, was observed excessively drinking from a tap once, but as she ‘was nursed on ten-minute observations, and had unsupervised access to water… it is not possible to know how much she consumed or over what period’.

Mrs Whitehead ended up over-hydrated, leading to severely low sodium levels causing fatal swelling in the brain

Mrs Whitehead was detained at Millbrook hospital in Sutton-in-Ashfield, Nottinghamshire, in 2021

Mrs Whitehead ended up over-hydrated, leading to severely low sodium levels causing fatal swelling in the brain. An inquest jury concluded in September that the failings had ‘probably more than minimally’ contributed to her death.

Her widower Michael, 49, of Rainworth, Nottinghamshire, said: ‘When Michelle [seemingly] fell asleep, staff should have realised 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.’ Mr Whitehead said his ‘warm, caring and easy to love’ wife had suffered a ‘total breakdown from the person she normally is’ in the last days of her life. He said the couple met as teenagers and were together 30 years and married for 22. Mrs Whitehead gave up her job as a nursery nurse when one of their sons was born with Down syndrome. She was then a full-time carer for 19 years.

The probe into her death found her excessive water consumption was due to psychogenic polydipsia, well documented in psychiatric disorders. But staff failed to diagnose the condition. She was given tranquillisers and seemingly fell asleep, but went into a coma. The jury heard staff did not realise anything was wrong until four hours later. Mrs Whitehead was admitted to King’s Mill Hospital, Mansfield, and died two days later.

The trust admitted eight failings which also included staff failure to adhere to policy after Mrs Whitehead was sedated, leading to inadequate assessments of her. There was also a delay in a doctor arriving, and in admitting paramedics to the building.

Ifti Majid, chief executive of the trust, apologised to Mrs Whitehead’s family for her ‘quality’ of care, and said the trust was considering the findings of the jury and coroner.

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