Husband Calls For Lessons To Be Learned Following Inquest

A husband has called on an NHS Trust to learn lessons after an investigation found staff did not follow observation policies in the days before his wife’s death at a mental health hospital.

Teresa Doherty, 43, was found unconscious in the bathroom of her room at Caludon Centre in Coventry by a member of staff about an hour after she had last been seen. She was found to have asphyxiated.

Following the mother-of-five’s death her family instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care under Coventry and Warwickshire Partnership NHS Trust, which runs the Caludon Centre.

An NHS investigation found, four days before her death, staff had relaxed Teresa’s 15 minute observations to every hour. Investigators could find no evidence in support of this decision.

The independent investigation also found that there was inadequate ongoing assessment and monitoring of Teresa’s mental health state during her stay, and no documented evidence of one to one support or planned therapeutic interventions.

Despite telling doctors ‘she wouldn’t think twice about ending her life’ the day before her death, her observation period was not amended.

An inquest has now heard evidence of how Teresa spent her last few days, which included her revealing to doctors how she was hearing voices and that she did not want to hurt anymore. Nonetheless, Teresa was kept under the same level of observations and was provided with no therapy or counselling sessions, the hearing was told.

Bina Patel, assistant coroner who sat with an 11 person jury recorded a narrative verdict, concluding Teresa “died as a result of her own deliberate act” but it was not known “whether she intended that act to cause her death.”

Teresa’s husband John, has joined his legal team at Irwin Mitchell in calling for Coventry and Warwickshire Partnership NHS Trust to learn lessons from her death.

Expert Opinion

This is an incredibly tragic case and, more than two years after Teresa’s death, John and the rest of the family remain understandably devastated by the loss of a much-loved wife and mum.

“The family had a number of concerns about the care Teresa received during her stay at the Caludon Centre, and sadly, the Root Cause Analysis Report validates these concerns.

“We now call on the NHS Trust to ensure it recognises the concerns that the NHS’s independent investigators found, hopefully meaning other families don’t have to suffer the heartache that John and the rest of Teresa’s family have endured following her death.” Laura Daly - Partner

Teresa and John, 41, had been married since 2002. They moved from Ireland to Nuneaton in 2014. In October 2015 Teresa had given birth to the couple’s youngest child.

Teresa had a 15 year history of anxiety and depression, an inquest at Coventry Crown Court was told. She had seen her GP a number of times, had taken medication and undergone short inpatient stays at hospitals, including in February 2016.

The hearing was told that on 20 February Teresa was accepted as a voluntary admission to the Caludon Centre. She was prescribed anti-depressants and placed on 15 minute observations. Over the coming days her mood remained low.

On 26 February, Teresa’s observation period was downgraded following a review between a doctor and nursing staff. 

On 29 February Teresa reported feeling ‘very bad’, that she ‘didn’t want to live anymore’ and ‘wouldn’t think twice about ending her life’, the Root Cause Analysis Investigation Report found.

On 1 March, 2016, Teresa was seen in a communal area at about 4pm. At 5pm a staff member went to check on her in her room and found Teresa unconscious. Staff tried to resuscitate her but she was pronounced dead.

Teresa died from a cardiac arrest caused by a lack of oxygen, the inquest heard.

The Root Cause Analysis Report found that a lack of information about the management of Teresa’s care and a lack of clinical explanation about why she was kept on hourly observations following her assessment on 29 February contributed to her death.

The report confirmed the Trust’s ‘contraband’ policy had been adhered to.
 
Speaking after the hearing John said: “I repeatedly told the staff to keep an eye on Teresa because I was very worried for her welfare. I knew my wife and what she had been through better than the staff but it felt like my concerns were just dismissed.

“I feel that the care plan and the medication Teresa was prescribed was not adequate in light of my concerns. I feel that if my concerns were treated more seriously my wife would still be here and her children would still have their mum.

“Our family’s only hope now is that the heartbreak we have suffered highlights the need for those with mental health issues to receive swift and appropriate treatment.     

“We hope that the Trust continues to learn from the issues which have been highlighted at the Inquest to ensure other families are spared the pain we have to endure on a daily basis.”

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