A 'kind and quirky' 19-year-old who was the 'life and soul of the party' ended her life in a five minute window between checks while on suicide watch at hospital. Sarah-Louise Doyle had been at a Merseyside mental health hospital for over two months when a support worker found her hanged.
Because she had been deemed at risk of self-harm, a hospital worker was required to check on her every five minutes. But on February 26, Sarah-Louise was able to kill herself between checks, and her death has prompted a warning from a coroner about the observations being too predictable.
Sarah-Louise, from Bootle, was described as 'always helping everybody out' but had struggled with her mental health, the Echo reports. Claire Buchanan, Sarah-Louise's mum, 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. She loved TikTok, she loved singing and dancing. It's hard to explain it.
"She was quirky; that is probably the best word." Sarah-Louise had been diagnosed with emotionally unstable personality disorder (EUPD) and anorexia and had been sectioned under the Mental Health Act in November last year.
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. Last December 16, she was moved to Alt Ward in Clock View, which is run by Mersey Care NHS Foundation Trust.
Andre Rebello, senior coroner for Liverpool and Wirral, described what happened next in a Regulation 28 report, designed to help organisations prevent the risk of future deaths. He 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 [room] and found Sarah [had hanged herself]."
Sarah-Louise was rushed to Aintree Hospital but was pronounced dead at 1.40am on February 27. Although the full inquest is set to take place later this year, Mr Rebello identified the fact the five minute checks were at regular intervals as a potential risk earlier in the process and sent the report to Mersey Care, Merseyside Police and Sarah-Louise's family.
Mr Rebello suggested that if the patient can accurately predict when a check is going to happen, they may be able to plan a self-harm attempt around it. He wrote: "On a review of the five minute observations, these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc.
"It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations... 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 about the case were also reflected in reports to the board of Mersey Care, which met on March 29. In the papers, a manager states: "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."
Mersey Care had also identified the lack of specialist alarms, which are activated if a patient tries to hang themselves, as long ago as Summer 2021, according to previous board papers. The trust says it is working to install the devices and introduce other measures highlighted following Sarah-Louise's death.
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 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.
