A "beautiful" mum's tragic death exposes the "fundamental flaws" in Britain's healthcare system, according to her heartbroken children.
The investigation into the death of Zainab Mohamed, which concluded on Friday, found a catalogue of errors at Clock View Mental Health Hospital, where the mum-of-two had been admitted for bipolar disorder on June 1 2021 following several weeks of manic symptoms.
She was found unresponsive on a bathroom floor on the afternoon of June 10, and was taken to Aintree Hospital, where she was placed on life support. She died on June 14, with a cause of death being cardiac arrest caused by asphyxia.
READ MORE: Final days of 'loving' mum found unresponsive at mental health hospital
Her children Amir and Halima said in a statement: "Zainab was our dear mother, she was a sister and daughter as well as a friend to many. Our mum was an incredible woman, she always had time for people and always put other people before herself. She loved her friends and family dearly.
"We are relieved that the inquest has concluded, but devastated to hear evidence of a catalogue of missed opportunities to engage with and understand her at Clock View Hospital. She had become increasingly withdrawn and only days prior to her death, had handed in to ward staff the same type of risk item that she used to take her life.
"Our mum had fought through her mental health difficulties for over 20 years. We struggle with the fact that she was only in Clock View hospital for 10 days before she carried out the act that led to her death."
The inquest found that Zainab, who had a history of bipolar disorder and schizoaffective disorder, had been subjected to aggressive racist verbal abuse from another patient at the hospital on June 3 - however, her family were not informed and staff made no attempt to follow up the incident.
The inquest heard that staffing levels were "frequently unsafe", which affected staff's ability to engage with patients. Food and fluid documentation was not properly filled in, and what was documented showed Zainab frequently refused to eat and drink during her stay. However, there was no discussion with Zainab about this, and the matter was not escalated. Staff also failed to question why Zainab was spending long periods of time in her room, which the court described as "a missed opportunity to explore her level of risk".
Amir and Halima said: "It hurts us that, when we thought our mum was going to a place that would keep her safe, she was going to a place where staffing levels made it unsafe. We appreciate that Covid may have played a role in this, but the fact of the matter is that we know that unsafe staffing levels on wards is an issue that still exists up and down the country.
"Our mum suffered an aggressive instance of racial abuse while at Clock View. The evidence heard at the inquest made clear that she found this distressing. Considering her vulnerable state, we were deeply upset to learn that staff failed to meaningfully engage with our mum to check she was OK. It is further distressing that we only learned about this incident after her death. Merseycare’s failure to inform the family denied us the opportunity to support her at the time.
"The fact that the food and fluid charts supposed to be filled in to monitor this were often left blank is saddening. Of the few charts that were completed correctly, they show that she would frequently refuse fluid and food. The fact that staff seem to have just accepted this without properly asking why feels wrong and was another missed opportunity.
"The inquest into our mum’s death has shown fundamental flaws in the way that inpatient mental health care is delivered in this country."
They added: "Our mum always had time for everyone, no matter what she was going through. Even when she was unwell, she would always focus on whether we were OK. She loved her music, loved to dance, and would always make you feel welcome. She was beautiful.
"We will never know why our mum did what she did on June 10, but we are relieved that the Coroner has confirmed what we suspected to be true – that there were a catalogue of serious missed opportunities where Mersey Care failed to offer the care that she deserved."
Coroner Anita Bhardwaj said: "Overall, there were a catalogue of serious missed opportunities to engage and understand the full clinical picture Zainab was presenting whilst on the ward. The racist incident possibly influenced her decision to do what she did on June 10 2021 to her to a degree, but to what extent would be pure speculation."
She added that measures put in place to restrict family visits to the hospital due to Covid-19 may also have influenced Zainab's decision if she had known about them, but that it was unknown whether she had been informed of the rules.
She handed down a narrative conclusion, which read: "Zainab Abdi Olad Mohamed was a 38-year-old lady who died of asphyxia... whilst she was suffering from a serious mental illness. Her intentions being unclear."
Mersey Care NHS Foundation Trust spokesman said...
"We are aware of the inquest into the death of one of our mental health inpatients and would like to express our deepest sympathies to the friends, family and loved ones of the deceased at this difficult time.
“We routinely investigate all serious incidents to explore how we can improve our practices, a process which is given even more urgency after a tragic event like this. Mersey Care prides itself as a learning organisation and we will also be reviewing the comments from the coroner and will identify any learning points within our organisation to ensure patient safety remains our highest priority.”
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