More could have been done to prevent the shocking death of a Burnley mum who hanged herself in hospital, according to the Blackburn Coroner.
Mum-of-three Mrs Jackie Williams (42), who suffered from depression, died at the Royal Blackburn Hospital after she deliberately hanged herself using a light chord on January 26th this year.
The risk of self-harm was not adequately conveyed to other members of staff.Blackburn Coroner Michael Singleton
Her heartbroken family attended a three day inquest at Blackburn Coroner’s Court, which ended with Coroner Michael Singleton saying her risk of self-harm was “not appropriately managed” by hospital staff.
Mrs Williams had been taken to the Royal Blackburn Hospital by ambulance after she was found collapsed by the side of the Leeds Liverpool Canal in Burnley.
The popular Burnley Asda cleaner had attended the same hospital on a number of occasions and took a deliberate overdose the previous November.
She had become depressed following the death of her father-in-law, who she had cared for, and had started drinking as a result.
When she arrived at the hospital at 10-50pm on January 26th, Mrs Williams was triaged by Sister Fiona Lamb who assessed that she presented a “moderate” risk of self-harm.
Sister Lamb told the inquest that she believed it was appropriate for her to be referred to the mental health liaison team at the hospital.
In the meantime, she was placed in a cubicle in the line of sight of the nurses’s station, with the door open.
However, a discrepancy in the evidence of Sister Lamb and the mental health liaison nurse on duty, Helen Wall, emerged during the inquest with both giving conflicting accounts over what was said in relation to Mrs Williams’ treatment.
This prompted the coroner to say: “In 21 years and 5,000 inquests I have never encountered such a conflict of evidence.
“I believe that both these women were giving what they believed were honest accounts, but there was a complete misunderstanding between them on the night.”
The inquest earlier heard that in September, 2014, Mrs Williams was diagnosed with depression by her GP Dr Alvey who prescribed her anti-depressants and advised she contact Inspire and a mental health team.
Mr Singleton, who concluded that Mrs Williams had deliberately taken her own life, said she could have been seen by a specialist mental health doctor in the hospital that night.
He said: “Mrs Williams was assessed to be a moderate risk of self-harm when she was admitted to the Royal Blackburn Hospital’s accident and emergency department.
“That risk was not appropriately managed because she was placed in a cubicle which had ligature points, namely the observation light chord.
“The risk of self-harm was not adequately conveyed to other members of staff. There was not an official referral to the mental health liaison team so that meant she was not assessed by them.
“I intend to compile a report in which I will set out my concerns rather than recommendations, which I will leave with professionals to carry out.”