The inquest into the death of Rachael Stubbs, who was a detained patient who died at the Meadows Unit, Cheadle Royal Hospital, Stockport at the age of only 17, heard some disturbing evidence in relation to defective monitoring of patients. Rachael Stubbs was apparently able to asphyxiate herself with a pillow, despite having ligatured herself less than three days previously and supposedly being under continuous observation with a specific direction to staff to stay within arm's length and to keep Rachael's neck and hands in view at all times. The Deputy Coroner called evidence including video evidence of the corridor in which the nurses supposedly observing Rachael were sitting. She concluded that the observations were "unarguably" out of arm's length and returned a narrative verdict with a number of important criticisms that have been made the subject of rule 43 recommendations. These included making recommendations about carrying out "level 4" continuous observations appropriately, making recommendations in relation to failures of record-keeping and criticising the failure of the nursing staff to carry out CPR immediately, rather than sending for help from someone else.
Rachael's mother, step-father and family were represented at the inquest by Stephen Simblet of Garden Court Chambers. Stephen was instructed by Fiona Borrill of Lester Morrill.
Click here to read a press report of the inquest.