Woman let down by failures in NHS Trust before taking her own life

An NHS trust has been called on to take urgent action after a woman at risk of suicide died after being found in her room in hospital. Katharine Tyrer, 44, was a patient on Lakefield Ward at Clatterbridge Hospital in Wirral when she died on April 12, 2018.

An inquest held by coroner for Liverpool and Wirral, David Lewis which ended on September 29 2022 concluded that Katharine Tyrer’s cause of death was suicide. The coroner flagged up a number of concerns, including “missed opportunities” to check on her between 11am and 12 noon in the time leading up to her death and an “underestimation of the risk Katharine Tyrer posed to herself”.

This was said to have been compounded by “inadequate risk assessment process and ward layout”, with Katharine having been moved from a room on the main corridor to one “tucked away”.

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Coroner David Lewis has now submitted a report to Cheshire and Wirral Partnership NHS Foundation Trust, saying that lessons need to be learned to ensure this does not happen again.

In his report, he states: “During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.”

Katharine Tyrer was a detained patient under Section 2 of the Mental Health Act, having been transferred to Clatterbridge Hospital from Aintree Hospital on March 28, 2018, where she had been admitted after suffering multiple spinal fractures as a result of a suicide attempt.

The coroner’s report states that her diagnosis at the time was emotionally unstable personality disorder, for which she had been receiving treatment, in line with national guidance. Katharine was described by the coroner as having been well known to staff on Lakefield Ward at Clatterbridge Hospital, having been admitted there as a detained patient and on a voluntary basis on a number of occasions.

The report states: “Katharine was well known to the clinical staff on the Lakefield Ward, having been admitted as both a detained patient and on a voluntary basis on a number of previous occasions, typically following impulsive episodes of self-harm or actions consistent with attempts to take her own life. It was known that these occurrences would often follow a ‘trigger event’, notably including disagreements with her husband.”

The report goes on to state that on April 11 Katharine asked for her level of observations to be reduced. They were then reduced, from L2, which is close observation, to L1, which is general observation. Later that day she told staff she was feeling “emotional and increasingly impulsive”.

On April 12, 2018 she left the ward at 10:07am, going outside to meet her husband. An argument ensued and their meeting was cut short. Her husband rang ward staff to make them aware of what had happened and to let them know that Katharine was returning.

She arrived back at 10.25am and, following the call from her husband, a clinical support worker visited her room to find her upset and crying. Katharine was offered and accepted medication, which was given at 10.40am by a nurse.

David Lewis’s report states: “Katharine was then left alone but shortly afterwards pressed her alarm bell to request assistance with her back brace. Four ward staff attended and helped, but had left again by 10.55am.

“They had no concerns, despite Katharine reporting that she felt sickly. A different member of staff saw her on the hourly observation round at 11am.

“Katharine was not seen again until 12pm, when a trainee nursing assistant performing the hourly observation round found her unresponsive in her bathroom.”

He added that Katharine died at the scene, “despite prompt CPR and 25 minutes of Advance Life Support”.

David Lewis went on to say that the Trust’s investigation found that, among other things, documentation around risk assessment and care planning had fallen short of expectations. A Trust witness said improvements had been made in those respects since Katharine’s death.

The coroner added that the court’s independent expert considered the ward layout ‘wholly inadequate’. The jury found that Katharine had taken her own life, but concluded that “missed opportunities to affect the outcome between 11am and 12am on 12 April 2022, as well as an under-estimation of the risk Katharine posed to herself, had contributed more than minimally to her death, as had the ward layout and inadequate risk assessment”.

He went on to state: “A number of rooms (including Katharine’s room, 23) were remote from the nursing station and largely out of sight unless visited for a specific purpose. Whilst I am aware that some changes have been made since 2018, I am concerned that the current layout continues to place vulnerable patients, who might take their own lives, at risk.

“It is appreciated that the Trust might not be in a position to create a ward which eliminates all of the layout issues. However, mitigation measures might be appropriate if the present facilities are to be used on an ongoing basis in an unmodified form.

Mental health support services

  • Age UK – 01606 720 434 (http://www.ageuk.org.uk/cheshire/our-services/)
  • Friends of the Elderly – Be a Friend Today Campaign 020 7730 8263 (http://www.beafriendtoday.org.uk/)
  • MIND -0300 123 3393
  • Samaritans – 08457 90 90 90
  • CALM (Campaign Against Living Miserably) – 0800 58 58 58 or text 07537 404717

“I am concerned that the limitations presented by the current layout may mean that staffing levels need to be adjusted to allow for greater levels of informal observation, oversight and monitoring.”

David Lewis said that the evidence indicated that ward staff, seemingly regardless of their level of experience and seniority, who attended a patient in a situation like this were left to determine what, if any, action to take based upon their clinical judgement. It was left to the individual to decide whether escalation to a senior clinician would be appropriate and whether observations or monitoring, or even simply staying with the patient, should be increased for a period of time.

He added: “I was told that it would not be unworkable in any scenario such as this (involving knowledge of a trigger event in the case of an impulsive patient with a known history of suicide attempts and self-harm) for there to be a procedure which called for an automatic review by the senior clinician on the ward at the time.

“However, that is not the current situation. I am concerned that, in the absence of a clear protocol, relatively junior staff (who may not be able to effect an adequate risk assessment) may not be equipped to determine how best to address the short-term risk.”

The reports concludes with Mr Lewis calling on the Trust to take action, saying: “In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.”

David Lewis has submitted the report to the chief executive of Cheshire and Wirral Partnership NHS Foundation Trust, and has asked for a response by November 25, 2022.

Gary Flockhart, Cheshire and Wirral Partnership NHS Foundation Trust, Director of Nursing, Therapies and Patient Partnerships, says: “We would like to express our deep and sincere condolences to Katharine’s family and friends. Following Katharine’s tragic death, the Trust conducted a serious incident investigation and immediately responded to the learning identified.

“The report provides further opportunities for the Trust to learn and we will provide a full response to the Coroner.”

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