Inquest identifies failings at specialist mental health unit following suicide

01 November 2017

Shoosmiths recently represented Nigel Hinks, a widower whose 43 year-old wife, Clare, committed suicide whilst an in-patient on Hill Crest Ward, part of the Worcester Health and Care NHS Trust in Redditch at the inquest hearing into her death.

Our client’s wife was admitted to Hill Crest Ward, which specialises in the assessment and treatment of people with acute episode mental illness, on 22 November 2016 having been considered to be a suicide risk by the Home Treatment Team. There were particular concerns as she had been found with a homemade ligature.

She was placed on observations every 15 minutes. There was evidence that this was the standard observation plan for all patients for their initial 72 hours on the ward. The Trust’s observation policy confirmed that meaningful one-to-one engagements should take place hourly.

On admission, staff removed the cord of a phone charger due to the ligature risk, but allowed her to retain scarves in her possession. On two occasions, members of staff reported that, whilst on the ward, the patient handed over those scarves as she felt unsafe with them. Despite this, no review of her possessions or observation care plan was undertaken.

At the inquest the staff confirmed they engaged in a practice of ‘positive risk management’, whereby, patients are trusted to remain with potentially risky items to encourage a positive relationship between the patient and the staff and also for the patient to build confidence with particular items so as not to see them as risky.

Our client’s wife was advised to approach a member of staff if she felt unsafe. The observation care plan was not reviewed after 72 hours as per the Trust policy and she remained on 15 minutes observations during her stay.

On the evening of 27 November 2016 she approached a member of staff to engage in a one-to-one. This could not take place as the member of staff was observing another patient at the time. There was no attempt by that member of staff to engage with her later during that evening or to request another member of staff speak to the patient.

During the early hours of 28 November 2016 she was found to have ligatured herself with a scarf that she had not handed over and had not been removed from her possession. The inquest heard that the patient was transferred to the local ITU department but was unfortunately unable to recover and died on 3 December 2016.

The inquest took place before a jury (as HM Coroner is obliged to do in cases when death is in a healthcare setting where a patient has committed suicide) and in delivering a narrative conclusion the Coroner identified the following failures:

  • There was insufficient evidence that an adequate observation care plan was developed on admission to Hill Crest and this shortcoming may have contributed to the patient’s death.
  • Although an admission care plan was completed, there were inadequate risk assessments completed during the patient’s admission. Ongoing risk assessment may have highlighted the ongoing risk regarding potential ligatures.
  • There was insufficient evidence to show a rationale for level two observations being continued. This subsequently showed an inadequate review of observation levels. It was noted the timings of observations did not appear to mirror the patient’s presentation.
  • There was a missed opportunity at the ward review to set out the rationale for the level of observations the patient was subject to.
  • There was inadequate engagement and care by nursing and healthcare assistants during the course of the patient’s admission. Given that the patient was known to be an intensely private person, any opportunity for engagement initiated by the patient should have been followed up in a timely fashion.
  • Observations were not performed adequately during the night time. Although it wasn’t detailed on the observation form, the patient was admitted due to suicide risk and had been seeking interaction earlier in the day. There was a lack of consistency in completing the observation forms which may have contributed to the failure of observations.
  • The approach to dealing with potential ligatures was inadequate and there were inconsistencies from the time the patient was admitted. There was no form to confirm the patient’s possession of scarves. There was an inconsistent rationale as to why scarves were left in the patient’s possession. There was an absence of clear strategy on potential restrictive objects.

Our client stated:

‘The death of my wife has had a devastating effect on me. This has been compounded by the Trust’s failure to accept any lessons could be learnt from her death. I am satisfied with the outcome of the inquest and the jury’s findings very much mirror the concerns I have had since my wife’s death.

All I have ever sought from the Trust is an apology and reassurance that steps will be taken to ensure that happened to my wife cannot happen to anyone else. I am pleased the Coroner will write to the Chief Executive of the Trust to ask that specific parts of their policy are reviewed.’

Amy Greaves, an associate solicitor in the firm’s medical negligence team, who represented the family at the inquest added:

‘This has been a very difficult process for our client, however, the outcome demonstrates that the concerns he raised were justified. Mental Health has been at the forefront of many people’s minds this year and it is important we continue to support the agenda to improve services for those who suffer with mental health problems.’

Media Coverage

Redditch and Alcester Advertiser

Husband of Clare Ineson from Hollywood wants lessons learned from her death while at Hill Crest in Redditch



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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