A teenager managed to take her own life in a five-minute gap between checks while on suicide watch in hospital. "Kind and quirky" Sarah-Louise Doyle, 19, was found hanging from a bathroom door by a support worker on February 26 this year - prompting concerns about the checks being too predictable.
Sarah-Louise, from Bootle, Liverpool, was described as "life and soul of the party", but had struggled with her mental health. She had been diagnosed with emotionally unstable personality disorder (EUPD) and anorexia and had been sectioned under the Mental Health Act in November last year, the Liverpool ECHO reports.
Despite her troubles, Sarah-Louise had been in her third year of a health and social care course at Hugh Baird College and dreamed of working with disabled children, according to her mum Claire Buchanan.
She said: "It's hard to put into words but she didn't let her mental health struggles show through. She seemed always happy, she would always help everybody out. She was the joker of the family. It's hard to explain it. She was quirky; that is probably the best word."
Sarah-Louise was moved to Alt Ward in the city's Clock View hospital, which is run by Mersey Care NHS Foundation Trust, on December 16, but was deemed to be at risk of self harm. A hospital worker was required to physically check on her every five minutes.
In a written report, Andre Rebello, senior coroner for Liverpool and Wirral, wrote: "On Saturday February 26, 2022, at 9pm a support worker took over responsibility for completing checks on patients as a result of their risk assessment. Sarah was on five-minute observations due to a risk of ligaturing. During the five minute checks there were no incidents of note.
"At 9.25pm the support worker went into Sarah's room where she was sat on the bed, replied she was ok when asked and the support worker left the room and closed the door. On checking at 9.30pm, the support worker could not see her sat on her bed so went into her and found Sarah [had hanged herself]."
Sarah-Louise was rushed to Aintree Hospital but pronounced dead at 1.40am on February 27 and a full inquest will be held later. Mr Rebello suggested: "In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations."
Concerns were also raised in reports to the board of Mersey Care, which stated: "A 72 Hour Review has been completed and shared with Clinical Commissioning Group and Care Quality Commission and a number of immediate actions identified and undertaken regarding the use and recording of supportive observations, door top alarms and the replacement of en-suite doors with magnetic, collapsible doors."
Mersey Care had pinpointed the lack of door-top alarms, which are activated if a patient tries to hang themselves, as long ago as Summer 2021, according to previous board papers. Mention is also made of installing anti-ligature bathroom doors in Mersey Care facilities as long ago as December 2020.
A spokesman for Mersey Care NHS Foundation Trust said: “Our thoughts go out to the family and friends of the deceased at such a difficult time. Mersey Care remains committed to providing the highest standards of safety for all our patients at all our inpatient units and we are constantly reviewing practices and protocols to ensure that happens.
"We have already implemented a rolling programme of replacing bathroom doors with collapsible doors and to install door top alarms, which is currently being completed at Clock View Hospital and will be extended across inpatient areas across the Trust. We pride ourselves on being a learning organisation and we have already carried out a full review of our use of unpredictable observation intervals across the Trust to ensure they are being implemented systematically and without exception."
A full inquest into Sarah-Louise's death is set to take place later this year.
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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