Coroner To Write To Welsh Government After Health Trust Knew About Danger Seven Months Before Woman's Death

A heartbroken family has spoken for the first time after a mum was found hanged in a hospital 18 months after concerns were raised about ligature points in its mental health unit.

The body of Deirdre Harvey, 52, was found in a bathroom at Royal Glamorgan Hospital on 10 April, 2017. She had been detained several weeks previously under the Mental Health Act.

The Healthcare Inspectorate Wales had raised concerns about ligature points with Cwm Taf University Health Board, which runs the hospital, in October 2015.

In August 2016 following a further review of ligature points on its mental health wards ordered by the Welsh Government, the Health Board identified a fitting from which Deidre, known as Dee, would later hang herself, as a potential ligature point which needed removing or redesigning. No adaptations were made before her death, after which the fitting was removed immediately.

Following the death of the mum-of-one, her family instructed specialist lawyers at Irwin Mitchell to investigate the circumstances leading up to how she took her own life.

After a two week hearing in Pontypridd before Christopher Woolley, Assistant Coroner for South Central Wales, an inquest jury has concluded that Dee’s death was an accident contributed to by neglect.  The jury also concluded that the death was caused by:

• Insufficiently frequent monitoring of Dee on 10 April, 2017
• The failure to remove the fitting in the bathroom
• The failure to have in place an adequate system to identify and remove ligature points on the ward where Dee was detained.

The jury also found that the following factors possibly contributed to Dee’s death:

• An underestimation of Dee’s mental illness by staff
• A failure to consider the impact of the medication Dee was taking for the skin condition lupus on her mental health
• A failure to appropriately treat Dee’s mental health by way of medication.

Mr Woolley said that he would be writing to the Cwm Taf University Health Board highlighting his concern that future deaths could occur as a result of inadequate systems for:

• Identifying when items of risk are removed from a patient’s locker and then returned to them
• Ensuring that staff are aware of risk assessments.

Mr Woolley also said that he would be writing to the Welsh Government raising concerns that future deaths may arise from the apparent lack of a system for making urgent funds available to Health Boards to address dangerous hospital environments.

Expert Opinion

This is an incredibly tragic case and, more than a year after Dee’s death her family remain understandably devastated by the loss of a much-loved mother, sister, aunt and daughter.

“Dee’s family has had a number of concerns regarding her death. The jury’s conclusion and the previous warnings the Health Board had received sadly shows that more should have been done to prevent Dee’s death.

“It is matter of particular concern that as long ago as October 2015 Health Inspectorate Wales had raised an “immediate concern” regarding ligature points and audits at the Royal Glamorgan Hospital. It should not have taken this death for the Cwm Taf University Health Board to remove such an obvious ligature point on the acute mental health ward at the Royal Glamorgan.

“It is now imperative that mental health wards throughout the country give urgent consideration to whether they are providing a safe environment for their patients.” Gus Silverman - Associate Solicitor

Dee’s daughter Rebecca, 22, said:  “Mam was such a loving and caring person who doted on her family.

“We hoped that in hospital she would receive the care and support she needed to get better so she could return to her family; instead she was failed by those who were supposed to help her.

“Our family has been left devastated by mam’s death which we now know was contributed to by neglect and a series of failings.  It has been very difficult to hear how the hospital knew about the exact ligature point my mum used for seven months before her death and didn’t remove it.

“All we can hope for now is that mam’s death highlights the need for mental health hospitals to treat patients in a safe environment so that hopefully other families won’t have to go through same experience we have.

“As a family we would like to thank the jury for the care with which it has examined this case and for the clarity of its conclusions.”

Background

Dee, of Tonyrefail, had lived with bipolar and had been supported by community healthcare teams for around 10 years.

In October 2016 Dee was admitted to the Royal Glamorgan Hospital after a relapse of her bipolar disorder. 

On 21 November Dee was discharged, before attempting suicide at home.  She was taken to accident and emergency but couldn’t be admitted to a mental unit due to a lack of beds.  Following a further suicide attempt on 8 December Dee was admitted to the high dependency unit at Royal Glamorgan Hospital and transferred to the mental health unit two days later. She told staff that she did “not regret what she did and wished that she had been successful in ending her own life,” an inquest at Pontypridd Coroner’s Court heard.

Throughout January and early February 2017 her mood remained low and Dee stated she wanted to take her life.

She was officially detained under the Mental Health Act on 21 February.

Throughout late February and early March 2017 Dee continued to display paranoid beliefs, very low mood, and expressed a desire to die.  She reported suffering from hallucinations and hearing voices. 

On the morning of 10 April 2017 Dee was found hanged in a lockable room on the ward.

A report from independent psychiatrist, Dr Judith Edwards, read to the jury said: “I formed the impression that staff often failed to appreciate how distressed and mentally ill Ms Harvey was and thereby underestimated her degree of risk.

“She frequently told staff how desperate she was, how she wanted to kill herself, but this was not always taken seriously.”

Following an inspection in October 2015 Health Inspectorate Wales raised “immediate concern” regarding ligature points and audits.

In its report published in January 2016 the watchdog said: “An audit of ligature points is required for the whole unit and the Health Board must ensure that audits are undertaken in line with the set timescales.”

In June 2016 NHS Wales issued a notice to mental health units in Wales saying all spaces such as bedrooms and toilets where patients could not be constantly monitored “should be designed, constructed and furnished to make self-harm or ligature as difficult as possible. All fixtures and fittings should be anti-ligature.” It followed concerns raised by a coroner investigating the death of a patient found hanged at another hospital in 2014 that adequate steps had not been taken to improve safety.  

The Health Board carried out its audit of potential ligature points in August 2016. The following month it applied for funding from the Welsh Government to carry out alterations.

Immediately after Dee’s death the fitting was removed.

Health Inspectorate Wales again visited Royal Glamorgan Hospital in January 2017. Its report published that April found that fittings in communal areas could pose a potential danger.

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