Jury finds gross failures in care contributed to a vulnerable detained patient

Sabrina, who was 32, had a long history of mental health difficulties and self-harming behaviour. After suffering a serious deterioration in her condition while staying with her mother, she was taken to Accident and Emergency on 30 October.

She absconded, deliberately ran into oncoming traffic and was detained by the police for her own safety. She was taken to the Eastbourne Section 136 suite (‘place of safety’), where on the morning 31 October she tied a ligature around her neck whilst in the bathroom, which was interrupted by nursing staff. She was constantly observed, assessed as being at ‘high risk of suicide’ and detained under section 2 of the Mental Health Act.

That afternoon Sabrina was transported in a secure ambulance to the Woodlands ward in Hastings, run by Sussex Partnership NHS Foundation Trust. She was noted to be highly agitated on arrival, at about 4:20pm.

The inquest, heard between 3-6 July 2017 before HM Assistant Coroner James Healy-Pratt and a jury, heard that:

• The nurses in charge of admissions at Woodlands were unaware of Sabrina’s self-harming behaviours on 30 and 31 October, or that she had been assessed at the 136 Suite as ‘high risk of suicide’;
• No risk or mental health assessment was undertaken of Sabrina on her admission to Woodlands (which was the ‘minimum’ expectation according to the Trust’s policy);
• No information at all about the proper level of observations for Sabrina was communicated to staff on the ward; and
• No care plan was completed for Sabrina, and mandatory basic formal admissions procedures were not followed.

Sabrina was only formally checked every hour, and when Woodlands carried out a check at 8pm, she was not in her room. When staff returned to attempt to find her five minutes later, Sabby was found with a ligature around her neck tied to the bathroom door. She had been on the ward for less than four hours.

The jury concluded:

• The lack of formal risk assessment by Woodlands staff had direct impact on Sabrina, as if she had a risk assessment and been on correct observations her risk of self-harm would have been reduced;
• Nursing staff at Woodlands did not effectively appreciate Sabrina’s needs, which resulted in a serious failure of her care;
• If nursing staff had followed the Trust’s admissions procedures and placed Sabrina on one-to-one observations, Sabrina’s opportunities to harm herself would have been greatly reduced;
• The opiate medication Sabrina had taken would have effected her respiratory system, potentially hastening her death. Although the source of medication and where it was taken is unknown, this was a serious failure of her overall care.

The jury commented:

“Overall if correct procedures were followed they would have had a positive effect on Sabrina and the level of care received. By not following procedures this had a clear and direct effect on her passing. This is a gross failing of medical care from staff at Woodlands”.

The jury therefore found that Sabrina tied a ligature around her neck, although the evidence did not disclose whether she intended the outcome to be fatal, and that this was contributed to by neglect.

CPR had been attempted on Sabrina by nurses and paramedics who arrived later, but was unsuccessful. The inquest heard that the South East Coast Ambulance Service missed its target time for responding to the call about Sabrina, partly because the crew was from a different county and could not locate the Woodlands Unit (which is within the site of the Conquest Hospital in Hastings). In response to Sabrina’s death, a ‘history marker’ has now been placed on Woodlands ward to assist in directing emergency response crews to its location.

A report by the Care Quality Commission (“CQC”) following an inspection of Sussex Partnership NHS Foundation Trust which included the Woodlands Ward in September 2016 had found that “the trust did not meet the fundamental standard related to safe care and treatment with regards to managing ligature risks to patients”. A follow-up inspection by the CQC after Sabrina’s death found the Trust had “failed to keep her safe”.

The Coroner announced that he would be writing a Prevention of Future Deaths Report regarding the ongoing lack of CCTV in the communal areas of the ward which might assist in locating a patient potentially at risk of self-harm.

Sabrina’s mother, Christine Lavers, said:

“Sabrina was a highly intelligent, loving and caring young woman, but she was very vulnerable and she was failed. She was let down by serious failures to assess her risks and observe her in a place where I thought she would be kept safe. The jury found that these basic checks could have prevented her death. All I want is that lessons are learned from this tragedy so that no more families are in this position. The Trust needs to take action now.”

Shona Crallan, the family’s caseworker at INQUEST said:

“The jury’s finding of neglect is a shocking indictment of the care provided to Sabby at Woodlands ward. Sabby was a highly vulnerable woman in crisis, badly let down by the very service that should have been best placed to support her. This highly critical conclusion reaffirms ongoing concerns about the inadequacy of mental health provision nationally. We are particularly concerned by the repeated failures in care found in relation to Sussex Partnership NHS Foundation Trust. There is clearly a need for an urgent independent review into mental health care by this Trust.”

Sabrina Walsh’s mother was represented by Tom Stoate of the Garden Court Chambers Inquests and Inquiries Team, instructed by Shaki Sanusi of Birnberg Peirce and supported by INQUEST.