An inquest jury has found there were “gross failings in care amounting to neglect” before a woman had a heart attack at a private mental health hospital due to complications from drinking excessive amounts of water.
Lillian Lucas, 28, known as Lily to her family and friends, died in September 2022 after being found unresponsive in her room on Milton ward at the Cygnet hospital in Kewstoke, near Weston-super-Mare, where she had been an inpatient since June.
An inquest jury at Avon coroner’s court found on Wednesday that opportunities were missed by staff to render care that would have prevented Lucas’s death, including a failure to monitor her worsening condition and inadequate response to her deterioration.
Lucas, who lived in Malmesbury, Wiltshire, was a mental health nurse who had previously been diagnosed with schizophrenia and had been admitted to various hospitals numerous times in the years before her death, the inquest heard.
On 8 September 2022 she was found unresponsive in her room after drinking excessive amounts of water and transferred to Bristol Royal Infirmary (BRI), the jury heard. She died the following day.
Postmortem examinations found she died of a heart attack and the impact of psychogenic polydipsia, when due to a mental disorder a person experiences an uncontrollable urge to drink water.
The jury concluded on Wednesday that there were “gross failings in her care amounting to neglect”. In the record of the inquest, the jury said the Milton ward was “understaffed at a level deemed to be unsafe”.
The jury said: “Lily was observed to be drinking excessively from approximately midday (on 7 September 2022) and staff attempts to stop her were inadequate. Lily’s mental and physical health deteriorated throughout the afternoon with staff failing to document Lily’s condition according to hospital policy.
“There was a failure to recognise the … psychogenic polydipsia and that continued excessive drinking could cause serious harm or death. Neither urgent nor adequate medical attention was provided nor sought in line with Cygnet policies. Throughout the afternoon there was a failure to adequately monitor her worsening mental and physical condition, including her vomiting and defecation in both her room and communal areas.
“Despite evidence and 15-minute visual observations, there was inadequate response and concern for Lily’s ongoing presentation. Physical observations were not performed until later in the evening. Opportunities were missed to render care which would have prevented Lily’s death.”
The coroner Dr Peter Harrowing said he had decided not to file a prevention of future deaths report because he was satisfied Cygnet had taken steps to address concerns raised, including about staffing levels.
A doctor who had treated Lucas before her admission to the Cygnet spoke during the eight-day inquest about possible reasons why someone would drink excessive amounts of water. Dr James McIntyre, a consultant psychiatrist, said psychogenic polydipsia could be caused by the side-effects of antipsychotic medication or as a symptom of the psychosis itself.
On 5 September, as Lucas’s condition deteriorated, she was prescribed clozapine, the inquest heard. “Lily had always feared being prescribed clozapine,” Lucas’s mother, Mary Curran, said in her statement. “Lily was aware of the possibility of severe side-effects.”
Lucas’s father, Paul, visited on 5 September and voiced concerns to the medical staff about the “severity of risk” of side-effects, the inquest heard. He was told by a doctor that the benefits outweighed the risks and assurance was provided that his daughter would be monitored, the jury was told.
On the opening day of the inquest, Curran read out a pen portrait of her daughter, who graduated from the University of the West of England in 2017 as a mental health nurse.
“Lily was beautiful, loving, generous and hilarious,” she said. “She was so carefree and fun, and so full of mischief. One of her nursing colleagues described her as a fierce and progressive mental health nurse. Lily knew what good nursing care and support looked like.”
A Cygnet spokesperson said: “We take our responsibilities to provide safe care extremely seriously and where lessons must be learned we are committed to sharing, implementing and embedding them.
“We acknowledge improvements were needed and we have since made a number of changes to ensure the delivery of timely, safe, person-centred care. Ensuring safe staffing levels is a priority and, alongside changes to our hospital management, we have increased staffing numbers across the service and reduced our use of agency and bank staff to ensure continuity of care.”
They added: “All nursing staff at Cygnet hospital Kewstoke have undergone additional training and we have employed a full-time physical health lead who works across the hospital to enhance the skill set of our staff team and support with key physical health monitoring where required.”
