Elvon Morton died aged 38 following a ‘heightened response’ when he became agitated while receiving treatment at Whipps Cross Hospital, reports Marco Marcelline

A “flawed” decision to sedate an agitated Black man who died at Whipps Cross Hospital was triggered by his “size, sex and race”, a coroner has ruled.

Elvon Morton, 38, from Leytonstone, died on 7th December 2022 from septic shock, and the drugs oxycodone (pain relief) and lorezepam (sedative).

On 6th December, Elvon called emergency services upon experiencing abdominal pain, vomiting, diarrhoea, dizzy spells and shortness of breath. He was taken to hospital by ambulance where it was noted that Elvon was profoundly dehydrated and had creatinine levels that indicated an acute kidney injury.

Elvon was catheterised while treatment commenced. The treatment, which included fluid resuscitation, antibiotics including paracetamol and oxycodone, and an abdominal CT scan, was given but Elvon continued to deteriorate.

As Elvon’s respiratory function declined, he was started on oxygen therapy, but he began to agitate and took steps to self-discharge.

Medical staff then took the decision to sedate him with a second dose of oxycodone and four milligrams of Lorazepam.

Elvon then went into cardiac arrest, and efforts to revive him continued for over an hour before his death was declared.

An inquest at the East London Coroners Court in Walthamstow determined that the combined effects of oxycodone and lorazepam and recent metabolic illness played a contributory factor on his cause of death.

It was accepted by the trust that the safer course for Elvon would have been to anaesthetise and intubate him at an earlier stage in treatment.

East London coroner Graeme Irvine wrote in a Prevention of Future Deaths report that “documentation of key stages in [Elvon’s] care was poor or non-existent”.

This lack of documentation meant that “some clinicians were unaware that Elvon was sedated, whilst others were ignorant of the fact that he had declined treatment”.

The coroner noted that hospital staff reacted to Elvon’s agitation with a “heightened response” leading to security officers being called.

The coroner said that “it was in this febrile atmosphere that the decision to utilise rapid tranquilisation, a simpler and faster process than anaesthesia and intubation, was made”.

Mr Irvine also argued that a failure in governance at the Trust meant that the case was not identified as a serious incident. This omission “gives rise to a concern that future deaths may follow due to an inability of the trust to identify, reflect upon, and remediate sub-optimal practice”.

A Barts Health NHS Trust spokesperson said: “We extend our heartfelt condolences to the family of Mr Elvon Morton. We are taking the inquest’s findings very seriously and are addressing the coroner’s concerns. Our efforts to improve our practices and enhance patient safety will continue to be a top priority.”

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