A grieving mum is terrified that she may never find out the truth of her son's sudden death on a mental health ward.
Silvia Gilmour's son Jonathan was found unresponsive on the floor of his room in the Intensive Psychiatric Care Unit at Glasgow's Leverndale Hospital in April, 2021.
The 31-year-old, who was diagnosed with schizoaffective disorder, was under a special supervision order which meant he should have been attended by a staff member at all times.
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But an internal review showed that, by the time Jonathan’s body was discovered, rigour mortis had started to set in, reports the Daily Record.
Staff later admitted they had not been in the room with him at the time he died, which was a breach of his care plan.
Mum Silvia, 68, has been left desperately seeking answers over Jonathan's care after a post-mortem report ruled his cause of death as ‘unascertained’.
Widow Silvia said: “If someone had been in that room with Jonathan they would have seen him stop breathing. They may not have been able to save him, but his chances would have been a lot better.
"Staff claimed he was watched at all times from the doorway before there was a shift change, but the person who took over said they found the door to his room closed and the lights out.
“They said they went in and found that he wasn’t breathing, but later the story changed and they said the door was closed for only 30 seconds. He was showing signs of rigour mortis when he was found.
“That can’t happen in 30 seconds. The timeline of events keeps changing and I don’t think I’ll ever really know what happened to Jonathan.”
Silvia also told how Jonathan had been taken off all his antipsychotic drugs the previous week due to concerns about side effects on his heart, but the review showed he had been given a dose of sedative on the day he died. His post mortem report stated that "it is possible that a cardiac arrhythmia (irregular heartbeat) occurred related to the effects of antipsychotic drug treatment.”
Jonathan also suffered a life-threatening reaction to one antipsychotic medication in 2014, which saw him fall into a coma with his kidneys and lungs failing. Silvia added: “The only reason they took him off the drugs the week before he died was because the duty doctor noticed that the time taken for his heart to recharge between beats was too high.
“They had the cheek to tell me that he was the worst he had ever been in those drug-free days. But he was in withdrawal. I don’t care how challenging he was to look after, at the end of the day, he was in that hospital to be cared for."
Silvia also claims she asked for Jonathan to see a neurologist because she feared his challenging behaviour was being caused by seizures, but says she was repeatedly fobbed off. The post mortem on his brain showed signs of cerebellar ischaemia (a blocked or bleeding blood vessel), ‘common in patients with a history of seizures’.
Silvia continued: “They kept saying that they didn’t think it was necessary for Jonathan to see a neurologist. But what was the harm in him seeing one to rule out possible seizures when he was still alive?
“People say things like this get easier with time, but they don’t. I’m constantly tortured by everything that’s happened knowing that my poor boy and I weren’t listened to. But at the end of the day, it’s Jonathan who has paid the price.
“He was failed and I want some justice."
The review into Jonathan's death acknowledged that staff had failed to properly carry out observations in accordance with his care plan. It also raised concerns about staff recording his medication in the months before his death.
A spokesperson for NHS Greater Glasgow and Clyde said: "We do not comment on individual cases for reasons of patient confidentiality, we would once again offer our condolences to Mrs Gilmour.
“Significant Adverse Event Reviews are carried out in line with national guidelines and are submitted to Health Improvement Scotland. Findings are then used to form improvement plans if required.
“The national framework for SAER is regularly updated to ensure that learning from such reviews is shared and implemented across organisations to improve quality of service.”
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