A disorganised admission process and poor communication between staff are among the factors which contributed towards the death of a vulnerable patient on a mental health ward, Guernsey’s Royal Court has heard.

Lauren Ellis died on the Crevichon Ward at Oberlands in October 2017.

Former mental health nurses Rory McDermott, aged 32, and Naomi Prestidge, aged 31, deny the charge of manslaughter by gross negligence.

The court saw CCTV evidence which shows the pair failed to carry out regular observation checks on 22-year old Lauren in the lead up to her death.

But the court has heard there were multiple factors which contributed to the incident.

The court heard from two authors of reports commissioned to look into the root cause of Lauren’s death. Dr Geraldine O'Sullivan, the author of two reports, said in her professional opinion, Lauren’s death was not caused solely by these two nurses not carrying out level two 15- minute observation checks. She said multiple factors contributed to her death.

She said she found there was a disorganised admission process for Lauren and a care plan was not put in place to manage her risk.

Dr O’Sullivan told the court it was not clear what the purpose of Lauren’s admission was and she said it was not clearly documented why Lauren had been prescribed level two checks. She told the court she could not actually find any evidence that Lauren had been prescribed these 15- minute observation checks.

Dr O’Sullivan said she found there was a common practice to automatically put all patients on 15-minute observation checks. She found during the course of her research that nurses on the ward did not see the point in them and because of that, there was a tendency for these observation checks to not be carried out.

The court has heard that during the night, the on-call psychiatrist was phoned by Rory McDermott and Naomi Prestidge to prescribe medication to Lauren. She said this was perhaps a missed opportunity. She said she would have expected Dr Bhintade to probe into Lauren’s condition at that point.

The authors of these reports did not interview the defendants as part of their reviews.

The trial continues.