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Jury finds gross failures and neglect contributed to the death of a vulnerable detained patient in Sussex Partnership NHS Foundation Trust ward
6 July 2017
HM Assistant Coroner for East Sussex James Healy Pratt
Hastings Coroner’s Court
3 – 6 July
An inquest jury has concluded that gross failures in providing basic care, amounting to neglect, contributed the death of Sabrina (‘Sabby’) Walsh, 32. She died on 31 October 2016 in Woodlands ward, part of Sussex Partnership NHS Foundation Trust, after less than four hours in their care.
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 inquest heard that no risk or mental health assessment was undertaken on Sabrina’s admission to Woodlands (which was the ‘minimum’ expectation according to the Trust’s policy). Contrary to the Trust’s policy, Sabrina was never placed on one to one observations during her admission, and no care plan was completed. The nurses in charge of admissions at Woodlands were unaware of Sabrina’s recent self-harming behaviours and that she had been assessed at the 136 Suite as ‘high risk of suicide’.
Sabrina had a long history of mental health difficulties and self-harming behaviour. After suffering a serious deterioration in her condition, she was taken to A&E by her mother 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 (‘place of safety’) suite and on the morning of 31 October tied a ligature around her neck whilst in the bathroom, but 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. 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, Sabrina was found with a ligature around her neck tied to the bathroom door.
The jury concluded that her death was contributed to by neglect, continuing: “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 has had a clear and direct effect on her passing. This is a gross failing of medical care from staff at Woodlands”.
Sabrina’s mother, Christine Lavers, said:
“Sabby 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.”
NOTES TO EDITORS
For further information, please contact Lucy McKay on 020 7263 1111 or firstname.lastname@example.org
INQUEST has been working with the family of Sabby Walsh since November 2016. The family is represented by INQUEST Lawyers Group members Shaki Sanusi of Birnberg Peirce and Tom Stoate of Garden Court Chambers.
1. 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”.
2. 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. 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).
3. 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.
4. Earlier this month an inquest found a number of failings by a hospital run by the same trust contributed to the death of another patient, Janet Muller who was sectioned under the Mental Health Act. There are also details of a number of other deaths.
‘The decision to publish the Cass report is an extraordinary victory for INQUEST… Belatedly, it lifts another layer of camouflage from the secrets, lies and impunity that prevail in large sections of the British state and make such terrible events not merely possible but more likely…What INQUEST, Celia Stubbs and countless others around the world – say, the Mothers and Grandmothers of the Disappeared in Argentina – keep reminding us is not just that the instincts of the powerful are wrong, but that they can also be defeated, however long it may take.’
– David Ransom, friend of Blair Peach and former editor of New Internationalist magazine