Inquest jury finds neglect and a series of failings contributed to death of Deirdre Harvey on mental health ward

Deirdre Harvey, 52, was found after taking her own life in a bathroom at the Royal Glamorgan Hospital on 10 April, 2017. She had been detained several weeks previously under the Mental Health Act.

The Healthcare Inspectorate Wales had raised concerns about ligature points with Cwm Taf University Health Board, which runs the hospital, as long ago as October 2015.

In August 2016 following a further review of ligature points on its mental health wards ordered by the Welsh Government, the Health Board identified the handrail from which Deidre, known as Dee, would later hang herself, as a potential ligature point which needed removing or redesigning. No adaptations were made before her death, after which the handrail was removed immediately.

In October 2016 Dee was admitted to the Royal Glamorgan Hospital after a relapse of her bipolar disorder.

On 21 November Dee was discharged, before attempting suicide at home.  She was taken to Accident and Emergency but couldn’t be admitted to a mental unit due to a lack of beds.  Following a further suicide attempt on 8 December Dee was admitted to the high dependency unit at Royal Glamorgan Hospital and transferred to the mental health unit two days later. She told staff that she did “not regret what she did and wished that she had been successful in ending her own life,” an inquest at Pontypridd Coroner’s Court heard.

Throughout January and early February 2017 her mood remained low and Dee stated she wanted to take her life.

She was officially detained under the Mental Health Act on 21 February.

Throughout late February and early March 2017 Dee continued to display paranoid beliefs, very low mood, and expressed a desire to die.  She reported suffering from hallucinations and hearing voices.

On the morning of 10 April 2017 Dee was found hanged in a lockable room on the ward.

After a two week hearing in Pontypridd before Mr CJ Woolley, Assistant Coroner for South Central Wales, an inquest jury concluded on 27 July 2018 that Dee’s death was an accident contributed to by neglect.  They also concluded that the death was caused by:

• The decision to return Dee’s dressing gown cord to her after it was removed in February 2017 following concerns about her safety
• Insufficiently frequent monitoring of Dee on 10 April 2017
• The failure to remove the bathroom handrail
• The failure to have in place an adequate system to identify and remove ligature points on the ward where Dee was detained

The jury also found that the following factors possibly contributed to Dee’s death:

• An underestimation of Dee’s mental illness by staff
• A failure to consider the impact of the medication Dee was taking for the skin condition lupus on her mental health
• A failure to appropriately treat Dee’s mental health by way of medication

Mr Woolley said that he would be writing to the Cwm Taf University Health Board highlighting his concern that future deaths could occur as a result of inadequate systems for:

• Identifying when items of risk are removed from a patient’s locker and then returned to them
• Ensuring that staff are aware of risk assessments

Mr Woolley also said that he will be writing to the Welsh Government raising concerns that future deaths may arise from the apparent lack of a system for making urgent funds available to Health Boards to address dangerous hospital environments.

Gus Silverman, a public law and human rights lawyer at Irwin Mitchell, representing the family, said after the inquest:

“This is an incredibly tragic case and, more than a year after Dee’s death her family remain understandably devastated by the loss of a much-loved mother, sister, aunt and daughter.

“Dee’s family have had a number of serious concerns regarding her death. The jury’s conclusion and the previous warnings the Health Board had received sadly shows that more should have been done to prevent Dee’s death.

“It is matter of particular concern that as long ago as October 2015 Health Inspectorate Wales had raised an “immediate concern” regarding ligature points and audits at the Royal Glamorgan Hospital.  It should not have taken this death the Cwm Taf University Health Board to remove such an obvious ligature point on the acute mental health ward at the Royal Glamorgan.  It is now imperative that mental health wards throughout the country give urgent consideration to whether they are providing a safe environment for their patients.”

Dee’s daughter Rebecca, 22, said:

“Mam was such a loving and caring person who doted on her family.

“We hoped that in hospital she would receive the care and support she needed to get better so she could return to her family; instead she was failed by those who were supposed to help her.

“Our family has been left devastated by mam’s death which we now know was contributed to by neglect and a series of failings.  It has been very difficult to hear how the hospital knew about the exact ligature point my mum used for seven months before her death and didn’t remove it.”

“All we can hope for now is that mam’s death highlights the need for mental health hospitals to treat patients in a safe environment so that hopefully other families won’t have to go through same experience we have.”

“As a family we would like to thank the jury for the care with which they have examined this case and for the clarity of their conclusions.”

Background

Dee, of Tonyrefail, had lived with bipolar and had been supported by community healthcare teams for around 10 years.

A report from independent psychiatrist, Dr Judith Edwards, read to the jury said:

“I formed the impression that staff often failed to appreciate how distressed and mentally ill Ms Harvey was and thereby underestimated her degree of risk.

“She frequently told staff how desperate she was, how she wanted to kill herself, but this was not always taken seriously.”

Following an inspection in October 2015 Health Inspectorate Wales raised “immediate concern” regarding ligature points and audits.

In its report published in January 2016 the watchdog said:

“An audit of ligature points is required for the whole unit and the Health Board must ensure that audits are undertaken in line with the set timescales.”

In June 2016 NHS Wales issued a notice to mental health units in Wales saying all spaces such as bedrooms and toilets where patients could not be constantly monitored “should be designed, constructed and furnished to make self-harm or ligature as difficult as possible. All fixtures and fittings should be anti-ligature.” It followed concerns raised by a coroner investigating the death of a patient found hanged at another hospital in 2014 that adequate steps had not been taken to improve safety.

The Health Board carried out its audit of potential ligature points in August 2016. The following month it applied for funding from the Welsh Government to carry out alterations.

Immediately after Dee’s death the fitting was removed.

Health Inspectorate Wales again visited Royal Glamorgan Hospital in January 2017. Its report published that April found that fittings in communal areas could pose a potential danger.

This case has been covered in the press including by the Guardian and Wales Online.

Sean Horstead is a member of the Garden Court Chambers Inquests and Inquiries Team.