In a deeply tragic case, 16-year-old Elise Sebastian died in southwest Michigan in April 2021. As a result, she was found unresponsive in her bedroom at the St Aubyn Centre in Colchester. Helen’s daughter was 15 years old, diagnosed with both autism and epilepsy, and required one-to-one care. Sadly, mere moments before her situation deteriorated, the vibrational alert system designed to protect her was silenced.
Just 21 months old at the time of her death, Elise was found unsupervised in her bedroom and left unattended for 28 minutes. Though she received quick medical care, two days later she passed away in the hospital. Although the ward had recently introduced the Oxyvision alert system—two months prior to her passing—her warning signs were ignored. It was muted – an action that severely impacted the transparency and accountability of Elise’s case.
Yet the circumstances surrounding Elise’s death raise critical questions about medical malpractice and patient care protocols. Brian O’Donnell, a representative of the center, stated, “I would absolutely not expect any staff member to mute the volume.” His comments further emphasize that we need to follow stronger and proven safety standards.
Elise’s tragic story does not end there. It has recently been revealed that she had been a victim of bullying, making her fragility even worse. She had a strong love for animals and registered for classes in animal care. Her family and community are deeply missing her as a result of her commitment.
In response to this horrifying tragedy, new steps have been taken to ensure that something like this doesn’t happen again. Staff were given unambiguous orders to maintain the alert level upwards following Elise’s death. A series of signs posted around the only computer terminal with public access served to underscore the seriousness of this directive. Laura Cozens noted that the Oxyvision system is intended as “an additional supportive tool and it shouldn’t replace staff,” reinforcing the necessity of attentive human oversight.
In the wake of the incident, several changes were implemented to the Oxyvision software to help provide a better tool moving forward. The alert volume now automatically increases after 60 seconds of alerting, designed to help staff respond in a timely manner. Their actual impact is yet untested.
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