Electric shock therapy death: Sunderland coroner writes to Health Secretary in bid to prevent further fatalities

Sunderland Coroner's Court HM Senior Coroner Derek Winter.
Sunderland Coroner's Court HM Senior Coroner Derek Winter.

A coroner is to write to the Health Secretary after a Sunderland hospital patient died following electric shock therapy.

Elsie Tindle, 71, suffered a permanent epileptic seizure which caused irreparable brain damage, an inquest into her death heard.

Sunderland Royal Hospital.

Sunderland Royal Hospital.

Her brain was completely starved of oxygen during the prolonged fit last year, a jury at Sunderland Coroner’s Court was told.

The jury ruled that she died as a result of a “rare complication following the lawful and necessary administration of electroconvulsive therapy (ECT)”.

The hearing, before Sunderland Senior Coroner Derek Winter, heard that ECT was decided upon by medics as a last resort after Sunderland Royal Hospital was unable to manage Miss Tindle’s mental health problems.

She had first been admitted to the hospital after a fall in November 2014, and she also suffered from depression and a learning disability.

ECT shocks the brain under general anaesthetic with muscle relaxant medication to minimise the risk of broken bones.

The inquest heard that, in order to perform ECG on a patient lacking the capacity to consent to it, a second opinion appointed doctor (SOAD) provided by the Care Quality Commission (CQC) must approve it.

An application for an SOAD was submitted on February 23, 2015, by psychiatrist Dr Eugene van Rheede van Oudtshoorn.

However, no SOAD had been appointed by the time Dr van Rheede referred Miss Tindle for ECT, carried out by the NHS Electroconvulsive Therapy Service at the Tranwell Unit, Queen Elizabeth Hospital, Gateshead.

She had three treatments without an SOAD in place after an administrative error led to one not being allocated to the case. After the jury returned its findings, Mr Winter told the inquest of his intention to compile a Regulation 28 report to prevent future deaths, which he intends to send to the Secretary of State for Health.

He said: “I’m going to prepare a Regulation 28 report to prevent future deaths.

“My concern is in the request and allocation of second opinion doctors in a timely way.

“The court heard that 82% of SOADs are appointed within five working days of the request, but that begs the question about the services provided to the others.

“Secondary doctors perform a valuable role. The inquest heard that with 25% of patients involved with an SOAD, some sort of change in plan is implemented, and in 3% of cases, the treatment plan is refused.

“I will formulate it into a Regulation 28 report to present to the Secretary of State for Health, who I believe is the person who can do something about this.”

While in hospital, Miss Tindle had been missing her sister Joan, who was reluctant to visit, and refused to take medication or food and would rip out her intravenous line.

She was considered a danger to herself and was detained under Section 3 of the Mental Health Act, which allows for up to six months’ hospital treatment.

Dr van Rheede said: “She had three treatments without an SOAD in place.

“With Elsie, we had seen a downward cycle in her health. There would have been consequences of not taking action. There was an ongoing deterioration.

“We have to make a calculated decision of the benefits of taking the opportunity now, before the situation becomes difficult or impossible, and that was the right time.”

The jury heard how one electrical impulse, which lasts a few milliseconds, is administered by two probes at each session, and aims 
to initiate a 30-second seizure.

Six treatments will put 40% of patients into remission, while 10 treatments work in 70% of cases.

Miss Tindle had three sessions of ECT on February 27, March 6 and March 10, returning to Sunderland after each one.

Although the third session appeared to have gone as planned, she fell ill the following day.

She was taken to the high- dependency unit, and died in hospital 25 days later, on April 4, 2015.

Dr van Rheede added: “It’s a very, very rare complication.

“I couldn’t find other cases where someone had gone into a seizure or status epileptica a day later.

“However, there are anecdotal reports of people developing epilepsy after ECT, perhaps one in 80,000.”

Home Office pathologist Dr Nigel Cooper, who performed the post mortem on Miss Tindle, concluded the formal cause of death as anoxic-ischemic brain damage, due to status epilepticus, due to electroconvulsive therapy.

‘People can be treated quickly’

A Care Quality Commission spokesman said: “CQC maintains a panel of doctors who are trained and experienced in providing second opinions under the Mental Health Act. Many doctors do this part-time alongside their other work, and are not available at all times.

“Although we can’t predict when they will be needed, with their help we normally try to provide a Second Opinion Appointed Doctor to a patient detained under the Mental Health Act 1983 within five days of receiving the request. Last year we achieved this approximately 82% of the time.

“Patients requiring more immediate attention can be treated without the presence of a Second Opinion Appointed Doctor under section 62 of the Mental Health Act, which ensures people are treated quickly in an emergency.

“We note the coroner’s report and the circumstances in this case. We will consider the findings in detail and we will respond accordingly.”