Hill Crest

Hill Crest 2017-12-11 Person 1 5 0

Inquest identifies failings at specialist mental health unit following suicide Access Legal Solicitors recently acted at inquest for 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. Clare was admitted to the unit 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. On admission Clare 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 also have taken place hourly. Clare was advised to approach a member of staff if she felt unsafe and on the evening of 27 November 2016 she did just that. However, the conversation and reassurance she sought never took place as the member of staff she approached 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 her. During the early hours of 28 November 2016 Clare was found to have severely harmed herself with items that had not been removed from her possession. The inquest heard that the she was transferred to the local ITU department but was sadly unable to recover and she died on 03 December 2016. The inquest took place before a jury (as HM Coroner has the discretion to do in cases when death is in a healthcare setting where a patient has committed suicide) and in delivering a narrative conclusion the jury identified a number of failures, including inadequate risk assessments during admission, observation levels that did not appear to reflect the patient’s presentation and inadequate engagement and care by nursing and healthcare assistants during the admission. The jury further commented that, given that Clare was known to be an intensely private person, any opportunity for engagement initiated by her should have been followed up in a timely fashion, adding that this and several missed opportunities such as an absence of clear strategy on potentially harmful possessions and objects, may have contributed to the patient’s death. Our client stated: ‘The death of Clare has had a devastating effect on me and our family. 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.’ He continued: ‘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 efforts to keep this on the agenda to improve services for those who suffer with mental health problems.’