Lorna Frances Cullen · Prevention of Future Deaths report

On 2nd January 2013 an investigation into the death of Lorna Frances Cullen was commenced.
The investigation concluded at the end of the inquest on the 26th February 2014.
I returned a short narrative conclusion.

In the early hours of the morning of Sunday 23rd December 2012, Lorna Cullen was seen falling from the upper level of a multi-story car park. She suffered multiple injuries and died. No other person was involved in the event.
There was a long history of mental health problems and at the time of her death she was under the care of the mental health services. Between the 17th and 21st December 2012 there was noticeable deterioration in her mental health. She referred to “living forever” and on the afternoon of the 22nd December 2012 she referred to herself as being “an action man”.

During the early evening of the 22nd December 2012 Lorna Cullen attended at the Emergency Department of Medway Maritime Hospital. She was triage assessed within 20 minutes of her arrival at the hospital. She was assessed as requiring a mental health assessment. She was noted to be “threatening suicide”. She was not assessed as ‘high risk’, meaning that she did not need immediate assessment and treatment but was expected to be assessed within the standard 2 hour period from the time of the referral to the liaison psychiatry nurse on duty. Less than twenty minutes later and before any assessment had been carried out, Lorna Cullen left the hospital. The next time she was seen was when she was captured on closed circuit television falling from the car park.

It became apparent that if the deceased had waited at the hospital she would not in fact have been seen until at least midnight and possibly later (more than twice the standard time). The reason for this was due to the fact that there was only one nurse on duty during the ‘late’ shift and in view of the fact that a mental health assessment takes between 2-3 hours the demand (the nurse on duty receives referrals from a number of different departments within the hospital) far exceeded the available staffing provision. It was apparent from the evidence of at least three witnesses that at the time of this death in 2012, patients in need of mental health assessment by the on-duty liaison psychiatry nurse were regularly waiting well in excess of 2 hours. The importance of a mental health assessment taking place as soon as possible after such a need has been identified is obvious. A specially trained psychiatry nurse is more likely to pick up on the more subtle indicators as to risk, that means it is more likely that appropriate management of that risk can be put into place thus affording the most effective preventative measures against self-harm and harm to others.

During the course of the inquest I heard evidence that as a result of review additional resources had been awarded to facilitate increased staffing levels and to provide a 24 hour service (previously there were no liaison nurses on duty after midnight) thus providing continuation of services before and after midnight. I was advised that the additional levels of funding remain in place until at least the end of September 2014. The effect of these resources has been to significantly decrease the number of patients who require mental health assessments and who have to wait in excess of 2 hours. It has meant that staff can properly research a patient’s history prior to or as part of the assessment which is not only essential so far as assessing the individual patient but is useful in assessing priority as between patients waiting to be seen.

The matter of concern therefore relates to the long term (ie post September 2014) liaison psychiatry nurse staffing levels covering hospital emergency departments.