Pamela Margaret Bailey · Prevention of Future Deaths report

On 4th April 2013 I commenced an investigation into the death of Pamela Margaret Bailey, aged 68. The investigation concluded at the end of the inquest on 13th January 2014. The narrative conclusion was: That Pamela Margaret Bailey was admitted to Hawthorn Ward, Northern General Hospital, Sheffield on 30th September 2012, and detained under the Mental Health Act 1983. She became an informal patient in December 2012 and during February and March 2013 both escorted and unescorted leave took place.
On 23rd March 2013 at approximately 1830 hours she left the ward without being observed. Her movements after that time are not known. She was found deceased on 29th March 2013 at a secluded location at Ladybower, Derbyshire. It is not clear what her intentions were when she left the ward or thereafter. The medical cause of death was 1a) Hypothermia.

Pamela Margaret Bailey had been an in-patient at Hawthorn Ward, Northern General Hospital, Sheffield from the end of September 2012. She was initially detained under Section 2 and Section 3 of the Mental Health Act 1983 but then as an informal patient from December 2012. The intention was for Mrs Bailey to eventually be discharged home and escorted leave was commenced, to be followed by unescorted leave. On the 23rd March 2013, Mrs Bailey was on the ward at about 1830 hours. She exited the ward, obtaining egress through a locked door likely having observed the key code required. She was observed at 1831 hours on CCTv walking away from the Northern General Hospital, which was not only the last sighting of her, but also the last evidence of her whereabouts. She was found deceased on the 29th March 2013 at an isolated, secluded location close to Ladybower reservoir, Derbyshire. For the period 23rd March to the 29th March it was both very cold and there was snow lying on the ground.

I have seen an action plan, which I am informed was created after the report of the Serious Incident Panel in September. It was last updated on the 9th January 2014.

(1) Door security – no final decision has been made yet, but my understanding is that it is proposed to introduce a system for all secure wards, whereby there are dual system involving key code and swipe card. Is this the proposed alternative to the current system, and bearing in mind it is now about ten months since this incident, when is it proposed such action should be taken?

(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management, having failed to obtain a replacement by contacting either existing staff or flex staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place.

(3) There was no photograph available, of Mrs Bailey, to the Police when she disappeared. This clearly raises a number of difficult issues, as to the obtaining and retaining of a photograph. What decisions have been made in this regard?