Inquest finds hospital failings contribute to death
An inquest into the death of a mental health patient has found that there were hospital failings.
These failing contributed to the suicide of Claire Greaves from Pontypool in February 2018.
The inquest records an open verdict in the death of Claire.
The mental health hospital she was placed at, Cygnet, say they have learned lessons. The Aneurin Bevan health board who placed her there say they are reviewing placements for patients with complex needs.
Claire Greaves campaigned for mental health and wrote about it too. She had anorexia and a personality disorder, from an early age.
She tweeted when she was moved to Cygnet mental health hospital that she wished to be closer to home.
Claire had been moved from Abergavenny’s Nevill Hall hospital to Cygnet after her parents were informed that it was the only hospital that could manage her two complex needs.
They thought it would be a positive move for Claire.
However, they became concerned with staffing levels and lack of access to therapy pretty quickly.
Claire was placed into long term segregation and seclusion. This left her parents unable to have contact for several weeks.
Their daughter reported that there was no furniture in her room, that a mattress was brought in at night but removed the next day, and there was lack of support for personal hygiene.
Claire’s parents were trying to have her moved closer to their home when she died.
Despite being on suicide watch every day between 5.00 and 6.00pm every evening, Claire was able to obtain a piece of fabric left outside her room. She used this to commit suicide in her room, alone.
The inquest into Claire’s death found several areas of concern:
- Long term segregation was detrimental to Claire’s mental health state and contributed to her deterioration
- Staffing levels either caused or contributed to her death
- Her care plan was not followed, leaving her alone in her room and key times unattended
The Care Quality Commission (CQC) also raised concerns about Cygnet before Claire’s death. It noted high staff turnover leading to lack of training, and lack of consistency leaving patients feeling unsafe.
“Claire’s death is tragic. It could have been avoided had her care plan been upheld. There were clear areas of concern and she had carried out self harm in the days leading to her death. Patients in mental health units are vulnerable and their behaviour can be chaotic and unpredictable. The Hospital Trust, the Hospital itself and staff on the wards owe a duty of care to each and every patient they provide care for. When that duty of care is breached, there can be tragic and far reaching consequences as in this case. ”
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