What happened
Joanna Bailey, 36, had a learning disability, autism, epilepsy and obstructive sleep apnoea. From October 2016 she was detained under the Mental Health Act at Cawston Park, a private assessment and treatment hospital near Aylsham, Norfolk, on the locked Lodge and Grange wards.
At night she used a continuous positive airway pressure (CPAP) machine for her sleep apnoea, which also reduced her risk of seizures. Her care plan required checks every 30 minutes. On the night of her death she was not checked for two hours.
She was found unresponsive in her bed on the morning of 28 April 2018. A registered nurse and five care workers, all trained in first aid, did not attempt resuscitation. Paramedics arrived by which point she had not been breathing for at least 18 minutes, and she died soon after.
The outcome
A five-day inquest with a jury concluded on 27 November 2020. The jury raised 11 concerns, including staff shortages, training, inaccessible patient information, governance, emergency equipment and communication with the family.
The coroner gave the cause of death as sudden unexpected death in epilepsy, primary generalised epilepsy, obesity and obstructive sleep apnoea. No prosecution is recorded in the sources opened.
The Care Quality Commission rated the hospital as requiring improvement. It closed in May 2021, and the operator, Jeesal Akman Care Corporation, went into liquidation in June owing almost £4m.
What went wrong
The plan required checks every 30 minutes. That night there was a two-hour gap, and nothing in the shift made it visible before she was found.
Six staff trained in first aid, one a registered nurse, did not begin resuscitation. They had the skill and did not use it.
The CPAP machine’s data showed 29 uses in her last 209 nights and none since January. Neither her parents nor her consultant neurologist were told she had stopped using it, although every previous placement had prioritised its use. She had 60 seizures in 18 months there, including the evening before her death, and was not referred to a neurologist.
What it teaches
The link to this casebook has to be stated carefully. The inquest concerned observation, resuscitation and physical health care, not a restraint. The statutory review of her death and two others found “excessive use of restraint and seclusion by unqualified staff” and called the records “unaccountably inadequate”, but did not blame restraint for her death.
The connection is the control, not the cause. Observation, monitoring and equipment checks sit closest to restraint and fail the same way: a task assigned, unqualified staff carrying it, no audit, and a gap seen only after a death.
Questions for the room
- Her care plan said 30-minute checks and she went two hours unchecked. What in that shift made it possible?
- You are the nurse who finds her unresponsive. What do you do in the first minute?
Evidence and limits
Confidence: confirmed. The statutory safeguarding adults review and two BBC News reports corroborate the cause of death, the inquest findings and the hospital’s closure. All three were read.
Two limits matter. The review covers three deaths and does not attribute Joanna Bailey’s death to restraint; its restraint finding is about the hospital’s practice. The inquest examined observation, resuscitation and physical health care. Nothing here should be read as a finding that restraint caused her death.
Proceedings concluded on 27 November 2020, so the page may be cited outward. No member of staff is named and no finding is made about any individual.
Our restraint reduction training covers the observation and recording that sit alongside any restrictive practice.
Sources
- Norfolk Safeguarding Adults Board, Safeguarding Adults Review: Joanna, Jon and Ben, 2 June 2021 · https://www.norfolksafeguardingadultsboard.info/assets/SARs/SAR-Joanna-Jon-and-Ben/SAR-Rpt-Joanna-JonBen_FINAL-PUBLICATION02-June2021.pdf
- BBC News, Cawston Park: jury raises 11 concerns over woman’s death, 27 November 2020 · https://www.bbc.com/news/uk-england-norfolk-55106221
- BBC News, Cawston Park: vulnerable patient deaths prompt hospitals warning, 9 September 2021 · https://www.bbc.com/news/uk-england-norfolk-58466839
Reviewed 20 October 2026.