A family have been left heartbroken after their 'kind and quirky' teen daughter was able to take her own life in a five-minute gap between checks by hospital staff.
Sarah Louise Doyle was discovered by a support worker while on suicide watch at Clock View Hospital in Walton on on February 26.
The 19-year-old, described as the 'life and soul of the party' and someone who was 'always helping everybody out', had struggled with mental health.
Her death has prompted concerns over hospital checks being too predictable for those at danger of committing suicide and calls for collapsible doors to be installed in the en-suite area of rooms.
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.
Despite her troubles, Sarah-Louise, from Bootle, 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.
Speaking to the Liverpool Echo, Claire 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."
On December 16 Sarah-Louise was moved to Alt Ward in Clock View, which is run by Mersey Care NHS Foundation Trust.
Due to her being deemed a risk of self harm, a hospital worker was required to physically check on her every five minutes.
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 26th February 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 bathroom and found Sarah.
"The support worker ran out of the room and requested assistance from colleagues who managed to remove ligature and commence CPR until paramedics arrived and took over."
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 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 identified the lack of door-top alarms 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.
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The following are helplines and support networks for people to talk to, mostly listed on the NHS Choices website
- 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.
- CALM Campaign Against Living Miserably (0800 58 58 58) is a leading movement against suicide. It runs a UK helpline and webchat from 5pm to midnight 365 days a year for anyone who has hit a wall for any reason, who need to talk or find information and support.
- PANDAS (0808 1961 776) runs a free helpline and offers a support service for people who may be suffering with perinatal mental illness, including prenatal (antenatal) and postnatal depression plus support for their family or network.
- Childline (0800 1111) runs a helpline for children and young people in the UK. Calls are free and the number won't show up on your phone bill.
- PAPYRUS (0800 068 41 41) is an organisation supporting teenagers and young adults who are feeling suicidal.
- Mind (0300 123 3393) is a charity providing advice and support to empower anyone experiencing a mental health problem. They campaign to improve services, raise awareness and promote understanding.
- Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts.
- Bullying UK is a website for both children and adults affected by bullying.
Amparo provides emotional and practical support for anyone who has been affected by a suicide. This includes dealing with police and coroners; helping with media enquiries; preparing for and attending an inquest and helping to access other, appropriate, local support services. Call 0330 088 9255 or visit www.amparo.org.uk for more details.
- Hub of Hope is the UK’s most comprehensive national mental health support database. Download the free app, visit hubofhope.co.uk or text HOPE to 85258 to find relevant services near you.
- Young Persons Advisory Service – Providing mental health and emotional wellbeing services for Liverpool’s children, young people and families. tel: 0151 707 1025 email: support@ypas.org.uk
- Paul's Place - providing free counselling and group sessions to anyone living in Merseyside who has lost a family member or friend to suicide. Tel: 0151 226 0696 or email: paulsplace@beaconcounsellingtrust.co.uk
The Martin Gallier Project - offering face to face support for individuals considering suicide and their families. Opening hours 9.30-16.30, 7 days a week. Tel: 0151 644 0294 email: triage@gallierhouse.co.uk
