New procedures after girl died at special school

A special school has made changes to the way it cares for children following the death of a 14 year old girl, an inquest heard.

Bethany Clemens died at Dame Hannah Rogers School in Ivybridge on 11 December 2011, where she was a student.

She was found not breathing and without a pulse in her bed just after midnight.

A nurse tried to resuscitate her with the help of other staff, but when ambulance crews arrived paramedics chose to cease CPR and Bethany was pronounced dead shortly after.

The 14 year old, from East Looe, boarded at the school four nights a week and occasional weekends.

She suffered from Retts syndrome and epilepsy, which left her in a wheelchair with limited speech.

A post mortem found that Bethany died from sudden death due to epilepsy (SUDEP) however in a written statement read out to the court, Bethany’s mum, Emma Oakes, claimed that she had never been warned that SUDEP was a risk.

She also had questions over how often Bethany was being checked at night and the numbers of staff on duty.

In the statement she said:

“If I had been aware of SUDEP and the inadequacies of the night-time care at the school I would have worked to preserve my daughters right to life.”

Evidence given by Deborah Satchell, the nurse who found Bethany, confirmed that the usual checks had been made on the children that evening and there was the usual number of staff on duty.

Chris Freestone, head of children’s services at the Dame Hannah Rogers Trust confirmed that changes had been made at the school since Bethany’s death.

A report written by Dr Carolyn Adcock, who gave evidence at the inquest, highlighted a number of areas for change.

Chris Freestone said: “We wanted to be part of the review that Dr Adcock carried out and all the learning points in her report have been put into place.

“For example, lifeline packs are now kept within close proximity of each child, we have mobile resuscitation trollies and we have set up a medical legal issues working group.

“We’re also having a number of open days so that all parents can come in and see the nursing plans for the care of their children.”

The school’s epilepsy training now covers SUDEP.

Coroner Ian Arrow named the cause of death as SUDEP and that Bethany had died of natural causes.

He said “I have been struck by the great deal of feeling in the room today.

“I am sorry that Bethany’s death has been brought to my attention.”

Emma Oakes was too distressed to speak to us after the findings, however she passed a statement through her solicitor, which said:

“I am very relieved that the inquest is over.

“I hope that both the Health Trust and the Dame Hannah Rogers Trust have learnt lessons from what has happened.”

The Dame Hannah Rogers Trust issued the following statement:

“It is always extremely distressing when a child sadly dies and our hearts go out to Bethany’s family.

“We care for many very vulnerable children with complex and life limiting conditions for which we provide a high standard of support and opportunities; Bethany with Retts Syndrome was one such child. “She was a lovely and delightful young lady and everyone at Dame Hannah’s misses her very much.

“We fully support Bethany’s family’s desire to make sense of their loss and we hope that the findings of the inquest today allow them to do this.”