JURY'S VERDICT: Failings at Harbour DID contribute to patient's death
Failings at Blackpool's flagship mental health facility did contribute to a young woman's death, it was ruled yesterday.
Experts at The Harbour, in Preston New Road, Marton, ‘inappropriately’ reduced observation levels on 20-year-old Sally Hickling and left her alone in her room for 21 minutes — more than double what they should have, her inquest was told.
A narrative verdict was recorded by a 10-member jury, who said Miss Hickling died from brain damage after she was discovered with ligatures around her neck in the incident, last summer.
It came just days after she was found in a bathroom and rushed to hospital after a previous suicide attempt.
“On July 13, Sally was put on level two observations,” the foreman of the jury told the hearing, held at Blackpool Town Hall.
“Evidence indicates this reduction was inappropriate so soon after the incident on July 9.
“Observations were not carried out properly, there was no evidence of an effective plan or procedure, or failsafe to ensure observations were carried out.
“There was also no evidence to show completed observations were recorded.”
Coroner Alan Wilson said he was satisfied Lancashire Care NHS Foundation Trust, which runs the £40m facility, had taken sufficient action to prevent future deaths by launching an independent review.
But he still plans to write to the trust after staff told the court they were checking on patients more frequently than 10 minutes – understood to be against policy.
He said: “While it’s commendable they are indicating to the court these steps, they should not be doing that.”
The foreman of the jury delivered the collective verdict after hearing evidence from several witnesses, including Harbour staff, a detective, and an independent mental health expert over a four-day period.
They were told that after months of anxiety attacks, mood swings, and laxative abuse, Miss Hickling – described as ‘impulsive’ due to her condition – checked herself into The Harbour for 72 hours following the death of her grandfather last March.
She was detained after worrying doctors with her behaviour, and at one point had a member of staff within arm’s length at all times.
Her observation level was dropped to level three following a period of stability, which saw her kept within eyesight, and later to level two– checks every 10 minutes.
On July 9, Miss Hickling was taken to A&E at Blackpool Victoria Hospital after being found with a ligature around her neck.
But days later, she told Dr Thirunavakkarsu Aravinth she wanted to come back to level two, he told the hearing.
Dr Aravinth, who was not an approved clinician under the Mental Health Act and had his paperwork signed off by Dr Chandrashekar Gangaraju, without Dr Gangaraju ever seeing Miss Hickling — a ‘deviation from his legal duty’ — agreed.
He said he wanted to build trust with Miss Hickling, and the decision was agreed by a team of experts.
Some staff expressed their concern, the court heard, and the decision was branded by expert witness Dr Carl Wilson as a ‘serious error of judgement’.
The hearing heard Miss Hickling spent the morning in a communal area on the ward, before returning to her room.
At noon, agency healthcare assistant Falitate Ego Olademeji — working her second shift at the hospital and her first on the ward — became responsible for carrying out 10 minute checks.
At 12.52pm, Ms Olademeji made her last scheduled check, police were later able to work out from CCTV footage.
Eight minutes later, Ms Olademeji was due to hand over to fellow agency worker Akinwole Fasakin during a 1pm observation, but he had been called to another ward and neither the handover or observation took place.
Mr Fasakin told the court he returned to the ward after 1pm and thought another member of staff would cover his duties for him.
At 1.13pm, 21 minutes after Miss Hickling was last seen, the CCTV footage showed Ms Olademeji, followed shortly by Nurse Bowes, re-enter her room, where they found her lying on the floor.
Paramedic Graham Fletcher said he and a colleague were called to the facility at 1.18pm, arriving at 1.25pm.
Staff had given Miss Hickling CPR and applied a defibrillator and, after 15 minutes, she began breathing again.
Miss Hickling was taken to Blackpool Victoria Hospital, where she died shortly before midnight on July 30.
The inquest ruled the cause of death as serious brain injury caused by self-strangulation.
Secondary factors were pneumonia, which Miss Hickling contracted in hospital, and her weight - which was around seven stone at the time of her death.
A spokesman at Lancashire Care NHS Foundation Trust said: “Our deepest thoughts and sympathies are with Sally’s family and friends and we would like to extend our condolences to them at this very difficult time.
“We would like to sincerely apologise to her family and friends for their loss and the shortcomings in the care that was provided to Sally before she died.
“An independent investigation took place immediately after her death and highlighted the need for some key quality improvements that have since been made. Recommendations from the investigation that have been acted on include increased medical leadership on the psychiatric intensive care ward, an improved process for the observation of patients and better arrangements for care planning with the involvement of family or carers that also enables the identification of risk of harm.”