Sunday, 16 February 2014

Neglect Verdict at Article 2 Inquest into Suicide of Voluntary Patient

Kings Healthcare member, Rachel Galloway (instructed by JMW Solicitors), has recently represented the family at an inquest into the death of a voluntary mental patient.  

S had been admitted to the SAFIRE unit in Park House at North Manchester General Hospital.

After a 4 week (Article 2) inquest, the jury found that S had taken her own life whilst the balance of her mind was disturbed and that her death was contributed to by neglect.  The jury found that S suffered from schizophrenia and a personality disorder; she experienced auditory hallucinations.  S was assessed as being too high risk for continued care within the community and a Psychiatrist indicated that urgent inpatient treatment was required.  There was a delay in finding her a bed and S was not admitted to hospital for a further 8 days.  S accepted that she needed inpatient care and therefore she was not sectioned under the Mental Health Act.  She was not clerked in or seen by a doctor at any point during her stay.  She was commenced on "general observations".  

The jury found that she should have been put on "within arm's length" observations.  Within less than 48 hours of being admitted to hospital, S was found in a toilet having used a ligature to end her life.  In the afternoon before her death, she had handed into staff a ligature and a lighter and told them that she was hearing voices telling her to kill herself; these voices were increasingly difficult to resist.  Despite this, the level of observations was not increased.  When D was found with the ligature around her neck, ligature cutters could not be found and there were additional failures in respect of equipment.  However, it could not be said that her death would have been prevented had the ligature been removed earlier.  

The jury were specifically asked to consider the events which took place during the afternoon prior to S taking her own life and consider whether or not the care that had been provided amounted to a gross failure to provide basic medical attention to a person in a dependent position that was directly connected to her death.  The jury found that there had been such a gross failure and "neglect" was found accordingly. 

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