Inquest finds multiple failings caused death of vulnerable patient

Leah was a nineteen-year-old female patient detained at The Dene Hospital under section 3 of the Mental Health Act 1983. She had been diagnosed with emotionally unstable personality disorder and complex post-traumatic stress disorder (PTSD).

The inquest heard evidence that Leah was a prolific self-harmer. In the days leading up to her death there was an increase in severity of her self-harming, she expressed suicidal ideation, and presented with triggers which ought to have altered her risk level. Despite this, Leah’s risk and observation level was de-escalated to the minimum acceptable level for any patient. On 12 July 2012, Leah was discovered by nursing staff unconscious in her bedroom with a ligature around her neck. It emerged that there was a delay of at least six minutes before the Ambulance Service were called.

The central issues at the inquest were whether Leah was appropriately risk assessed, whether her level of observations were appropriate to her risk, record keeping, handover of information between staff shifts, and the adequacy of the emergency response. In a highly critical narrative, the jury found the following:

• It was not clear from notes or records available to staff on the night shift on 10 July 2012 what the expected level of observations were for Leah
• A formal risk assessment had not been appropriately performed on 10 July 2012
• All staff on duty on 10 July 2012 were not aware of recent factors affecting Leah’s risk
• Staff did not take appropriate action to respond to Leah’s behaviours, feelings, and up-to-date risks on 10 July 2012
• Staff did not adhere to the risk assessment policy and accurate records were not kept
• Leah presented with features on the 10 July 2012 that altered her risk level
• The level of observations for Leah Styles on the night shift of 10 July 2012 was not appropriate
• The risk assessment procedure adopted during the day shift of 10 July 2012 was not appropriate
• The record keeping for Leah’s observation levels and risk assessments in hospital notes was not consistent or appropriate
• The emergency response procedure after Leah was found on her bedroom floor was not appropriate

The jury also concluded that the minimum observations and the minimum risk level was a causative factor leading to Leah’s death. After legal submissions, the Coroner removed a short-form verdict of suicide.

Ifeanyi was instructed by Clare Evans of McMillan Williams Solicitors.

Ifeanyi Odogwu is a member of the Garden Court Inquests Team.