Inquest into death of Hackney mental health patient highlights lessons to be learnt
Posted on: 19th February 2016
An inquest into the death of a Stoke Newington woman who committed suicide while on leave from Larch Lodge in Hackney, a mental health unit run by East London NHS Foundation Trust, has highlighted a number of lessons to be learnt.
The Senior Coroner, Mary Hassell, reaching a decision of suicide into the death of 66-year old Brenda Morris, said she will be submitting a Prevention of Future Death Report (PFD) to the Chief Coroner to be implemented by all psychiatric units.
Brenda Morris, a former legal production and copy editor, had a complex medical history of neurological pain with anxiety, which in the last year of life she had found increasingly difficult to manage. After attempting suicide on 28 June 2015, she was admitted as an informal patient to Larch Lodge on 7 July.
Ms Morris was risk assessed as high/moderate risk but was allowed to leave the ward and took her own life in the bath of her Stoke Newington home on 20 July, while her partner Martin Turner had gone out. He was not informed of the ward’s evaluation of her risk, or given any advice on looking after her,
Following Brenda Morris’ death, the East London NHS Foundation Trust published a Serious Incident Report in October 2015 which found that there was an element of predictability about Ms Morris’ final suicide attempt and that:
- there was a lack of documentation of risk assessments and little evidence of the risk assessment process being followed;
- The nurse in charge and duty doctor should have carried out a risk/benefit discussion with Ms Morris. Further, they should have communicated to her partner a care plan that indicated she was not to be left unsupported.
Julie Say, medical negligence lawyer at Hodge Jones & Allen and Rob Harland, 7 Bedford Row Chambers represented the family. Speaking following the one-day inquest at Poplar Coroner’s Court on 18 February 2016, Julie Say of Hodge Jones & Allen says: “The inquest was a thorough examination of the facts that must contribute to safer practices for informal patients on psychiatric units throughout the Trust. A similar event really cannot be allowed to happen again and lessons must be learnt.”
Martin Turner, aged 68, attended the inquest, along with his and Brenda’s daughter, Kathryn, he said: “”We must hope that some good comes of this. People whose loved ones enter units such as Larch Lodge are entitled to believe they are receiving quality treatment from competent professionals. Families and carers need to be included and kept informed. They must be given appropriate advice on how to look after vulnerable relatives when they are discharged, or released on leave and be alert for signs of potentially suicidal mood swings. Psychiatrists and managers need to change their stubborn refusal to admit their shortcomings. Perhaps the coroner’s conclusions at the inquest into the suicide of my lifelong partner Brenda Morris will help to avert future tragedies and heartbreak.”
Kathryn Morris, aged 38 said: “Nothing can ease the pain of losing my beautiful mother in such tragic circumstances. But I believe valuable lessons can be learned from our experience, as highlighted by the coroner. There needs to be better collaboration between mental health professionals and the families of those at risk, that includes dialogue about care plans and education about warning signs. Families also need to feel confident that those managing mental health facilities are adhering to their own policies and risk assessment procedures. Above all we all need to learn to talk about suicide; I truly believe that further tragedies can be averted by bringing the subject into the open and building collaborative relationships between carers, health professionals and patients.”
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