NHS trust apologises after patient’s strangulation death

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A HOSPITAL neglected a suicidal woman who had access to belts, shoelaces and a cigarette lighter while being treated for her mental health problems, an inquest found.

Maria Evans, aged 20, was found dead in a bathroom with a dressing gown cord wrapped around her neck in a secure unit at Sheffield’s Northern General Hospital.

In the weeks before her death, Maria managed to obtain shoelaces to use as ligatures and a lighter to burn her arms, despite being under constant observation in the Longley Centre’s intensive treatment suite.

And just days before the tragedy in November 2009, her care was relaxed to round-the-clock checks every five minutes, Sheffield Coroner’s Court heard.

Coroner Christopher Dorries, who recorded a narrative verdict, said there was ‘no compelling evidence’ that Maria intended to kill herself, adding her death was ‘contributed to by neglect’.

“While this was a deliberate act, it was part of a long series of self-harm incidents and although Maria may have been reckless as to her safety, there is no compelling evidence that she intended to die on this particular occasion,” Mr Dorries said.

“Maria’s propensity to self-harm was clearly recognised and significant measures had been put in place to protect her life.

“However, these measures - frequency of observations and the restriction of items that might form a ligature - were not followed on the day of her death despite being clearly set out in the care plan.

“Accordingly, Maria’s death was contributed to by neglect.”

A pathologist gave the cause of death as ligature strangulation.

Kevan Taylor, chief executive of Sheffield Health and Social Care NHS Foundation Trust, said an internal inquiry into the incident has since been carried out, which highlighted a number of areas for improvement.

He added: “We would like to apologise for the events which resulted in Ms Evans’ death.

“The trust recognises the very serious nature of the incident.

“A comprehensive action plan is now in place in which all the recommendations have either already been addressed or are in progress.

“The trust is determined that as a result of this extremely sad event we offer a safer, more supportive service.”

Maria, who went to school in Shiregreen and Firth Park, suffered from borderline personality disorder and was admitted to the unit under the Mental Health Act after she climbed onto a roof and threatened to jump.