A concerned husband warned hospital staff about his wife less than two hours before she was found dead in her room's bathroom.
Katharine Tyrer was transferred from Aintree Hospital to the Lakefield Ward in Clatterbridge Hospital on April 3, 2018. The 44-year-old suffered multiple spinal fractures when she jumped into the River Mersey in an attempt to take her own life and she was detained under section two of the Mental Health Act.
In a report published to prevent future deaths, it said Katharine was well known to clinical staff on the ward after being admitted both as a detained patient and as a voluntary patient on a number of occasions. This was usually following "impulsive episodes of self-harm or actions consistent with attempts to take her own life".
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It was also noted in the report that these episodes would follow "trigger events". Her diagnosis at the time of her admission was emotionally unstable personality disorder which she was being treated for at the time. Previously she had been diagnosed with schizophrenia, which had been dropped to a secondary diagnosis in 2016.
Three days after being transferred to the hospital, she was moved from the main corridor of the ward to a room tucked away which was further from ward staff. On April 11 Katharine asked for her level of observation to be reduced. The following day, Katharine left the ward around 10am to meet her husband but the meeting was cut short.
He rang the ward to tell staff what had happened and that she was returning, with Katharine returning to the ward at 10.25am. Due to the call, a clinical support worker visited her room and found her crying and upset. Medication was offered and accepted, with the medication being given at 10.40am before she was left alone. Shortly afterwards, Katherine pressed her alarm to request assistance with her back brace.
Four ward staff members attended and helped before leaving at 10.55am with no concerns despite Katharine reporting she felt sickly, with a different members of staff checking on her at around 11am for her hourly observation. Katharine was not seen again until 12pm when a trainee nursing associate, performing an hourly observation, found her unresponsive in her bathroom. Despite prompt CPR and 25 minutes of advanced life support, she died at the scene with the death being concluded as suicide.
A jury found that Katharine had taken her own life but concluded that there were "missed opportunities to affect the outcome between 11am and 12pm" as well as there being an underestimation of the risk that she posed to herself. It was also found that the ward layout and inadequate risk assessment played a part in the death.
Assistant coroner David Lewis wrote in the report that he was concerned that the ward layout didn't "lend itself to easy observation of patients" with the court's independent expert finding it "wholly inadequate". The current layout is said to "place vulnerable patients, who might take their own lives, at risk", with staffing levels needing to be adjusted for greater levels of observation, oversight and monitoring.
Another concern of the coroner was that staff of any seniority are left to make the decision on whether what, if any, action is needed. The coroner said: "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."
Writing to the Chief Executive of the Cheshire and Wirral Partnership NHS Foundation Trust, Mr Lewis said: "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."
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 Tyrer’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.”
Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you're feeling, or if you're worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org.
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