Another life lost by inadequate care

Another life lost by inadequate care

By Liz Lockhart

We are sad to report yet another death of a young woman whilst in the care of a psychiatric  unit.

Kirsty Brookes, 19, was found hanged in woodland, the day after she escaped from Glenfield Hospital’s Bradgate Unit.

The coroner for Leicester concluded last Friday that if care plans to keep Kirsty safe had been carried out by health care professionals, the opportunity for her to abscond and take her own life would not have occurred.

Catherine Mason, coroner, summed up  at the end of a four day hearing by stating that Kirsty Brookes took her own life, in part, due to neglect.

She added ‘ Despite the known existence of a real and immediate risk to Kirsty’s life from self-harm, she had been able to abscond due to not being observed and detained in accordance with her needs are care plan.’

Kirsty had tried to hang herself on a previous occasion and was prone to self-harm, she had also absconded several times before.  She should have been on constant supervision but was only being observed every 15 minutes.

Last year, on June 19th, Kirsty climbed a security fence surrounding a garden at Bradgate Unit.  It emerged during the hearing that some staff were not aware that Kirsty was not allowed into the garden on her own because there was no hand-over to those working the afternoon shift.

The ward’s deputy manager, nurse Lisa Moyo, did not report Kirsty as missing to police for some 20 minutes after she had absconded.  She also omitted to tell the police that she was a high-risk patient which further delayed a police response.

The hearing heard that the constable assigned to search for Kirsty took two hours to begin a search as he waited for a police car.  He could have made the 15-minute journey on foot.

Kirsty’s parents were informed that she was missing by the police and not by the unit the inquest heard.  Kirsty was found hanged the next day in woods in Leicester.

Mrs. Mason said that inadequate staffing levels at the unit had meant that crucial information about Kirsty did not get passed on to all those caring for her on the day that she escaped.  There was no evidence that the Leicestershire Partnership NHS Trust, which runs the unit, had taken action to address the issue since Kirsty’s death.  She also said that she would write to ask the trust to look into the issue.

Kirsty’s parents, Glyn and Angie Brookes, said after the inquest that their daughter had been let down by the system which they had trusted to keep her safe.

‘I’m very disappointed with the trust and the care my daughter was given.  I’m sure lessons will be leant by the NHS and police and all we can hope for is other families will benefit from what comes out of this.’ said Mr. Brookes.

‘It’s very upsetting to know our daughter could still be alive if certain procedures and policies had been followed’ Mr. Brookes added.

The trust has carried out a review following Kirsty’s death which has resulted in a number of changes, John Short, the trust’s chief operating officer, said.

Improving communication between the ward team, ensuring patient records were completed to a higher standard and giving ward staff increased supervision to help them support more challenging patients were included in these changes.

‘We recognize there were a number of failings, and although we have actioned many of these already, we will be taking urgent action in relation to the coroner’s concerns about our ability to increase staffing levels at short notice’ Mr. Short said.  He added that the trust fully accepted the coroner’s verdict and offered his condolences and apologies to the family.

Mental Healthy is saddened to report on this case.  It seems all too often that we report on similar events and hope that changes really are being made.  

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