Laura Hill · Prevention of Future Deaths report

On 19th December 2012 an investigation into the death of Laura Hill then aged 21 was commenced. The investigation concluded at the end of the inquest on 27th November 2014. The conclusion of the inquest was a narrative verdict namely that the deceased had suspended herself by a ligature from the branch of a tree in a wooded area near to the Springfield Retail Park on Fishguard Road, Haverfordwest but the question of intent remains unclear. The medical cause of death was hanging.

(1) The deceased had had a difficult time growing up which saw her bullied at school, suffer depression and begin taking controlled drugs. She also lost a young son in January 2011 and her boyfriend of the time took his own life in August 2012.
(2) On 11th December 2012 the deceased took a large overdose of prescription tablets which nearly killed her. She was admitted to and treated at Withybush General Hospital for a period of 4 days and then transferred as a voluntary patient to the St Caradog Ward (‘the Ward’) at Bro Cerwyn Hospital in Haverfordwest.
(3) On arrival at Bro Cerwyn, the deceased was assessed as having “varying suicide risk” and it was felt that she would benefit from admission in view of her depression, substance misuse, unresolved bereavement issues and recent suicide attempt. She was placed on Level 2:15 observations. At this time she was described as “jovial, bright and interacting well with others”.
(4) At 19.15 hours that day the deceased attended to leave the Ward in order to source heroin. Staff on the Ward tried to dissuade her from leaving but she was adamant. She was allowed to discharge herself against medical advice.
(5) In the early hours of 16th December the deceased was returned to the Ward by Police Officers who had detained her under section 136 of the Mental Health Act.
(6) Upon readmission to the Hospital the deceased was emotional, in a distressed state, sobbing and tearful. The assessing doctor, placed her back on Level 2:15 observations and stated that should she seek to leave again then consideration
(7) At 14.45 hours on 16th December 2012, the deceased absconded from the Ward. Staff on Ward did not see her leaving the Ward. The alarm was raised by other patients. Staff from the Ward pursued her and persuaded her to return back to the Ward. The assessing doctor was not notified of this attempt to abscond nor was there a further assessment of the deceased’s mental health.
(8) At approximately 18.15 hours later that day the deceased absconded from the Ward again. When a member of staff got to the door of the Ward she was nowhere to be seen. The Police were notified and there was an extensive search to try and locate her.
(9) The deceased was found hanging from the branch of a tree in a wooded area near to the Springfield Retail Park at approximately 0.75 hours by members of the public.

(1) That there appears to be a breakdown in the transition and passing of information between the Child/Adolescent and the Adult Mental Health Teams.
(2) Staffing levels on the Ward need to be reviewed as it was felt that staffing resources were stretched at the relevant time (1 nurse and 3 support workers on a 16 bed acute ward).
(3) There was a training need identified in relation to the section 136 procedure when patients are handed over by the Police.
(4) There was a training need identified in relation to what constitutes ‘absconding’ and what should be done by staff following an incident of absconding.
(5) The door policy on the Ward needs to be reviewed as a patient was able to abscond without staff noticing.
(6) There was a training need identified in relation to Personality Disorders.
(7) There was a training need identified in relation to powers of detention and when those powers can and should be used.