Brenda SHIELDS · Prevention of Future Deaths report

On 15 December 2022 I commenced an investigation into the death of Brenda SHIELDS age 57. The investigation concluded at the end of the inquest on 6th June 2023 . The conclusion of the inquest was:

Death from self-suspension while her cognition was seriously impaired by a very high blood alcohol level.

1a Hanging

1b

1c

II Alcohol dependence

The record of inquest read as follows: "Brenda Shields died in her home ████████ , Carlisle on 8th December 2022. She took her life by ligature suspension while under the influence of a very high blood alcohol level". A narrative conclusion was given.

Brenda worked as a healthcare assistant in A&E at Cumberland Infirmary, she had for some time been alcohol dependent with binge sessions which often caused domestic friction with her husband, there was an incident of domestic violence requiring police involvement. Matters had been worse since she developed cauda Equina Syndrome which required neurosurgical intervention in 2021, and had ongoing low back pain which she tended to medicate with alcohol. She had episodes of anxiety in 2005 & 2007, depression on 2016 & suicidal ideation in 2018. On 26/10/22 she was admitted to A&E in Carlisle (her own workplace) with an intentional overdose. She was followed up and treated by her GP. On 10/11/21 there was a serious incident when she was found by police on the riverbank, she had intended to enter the water but was talked down from this by her GP. Brenda was admitted to hospital [Hadrian unit] as a voluntary patient.

Brenda was not comfortable in the ward environment and on 14/11/21 discharged home to be followed up by the Crisis Team who did visit her at home the following day. Brenda's GP not informed of her admission or discharge so was unaware of events until a prearranged telephone call on the 15th. Brenda was followed up at home and by telephone, at several contacts she was noted to be under the influence of alcohol. Brenda was discharged after a final "MDT" meeting on 6/12/22 [it is not clear who was involved], declining further input and denying any thoughts of self harm, a risk assessment on 8/12/22 records low or no apparent risks, this was the day Brenda died.

(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.

(2) Inadequate weight seems to have been given to Brenda's alcohol problems and her assurances that all was, and would continue to be well were accepted at face value despite her recent history, her family find it hard to understand how she could be graded low risk on the day she died.

(3) I refer you to the PFD report I issued referring to Charlotte Grace on 29/10/19. Assurances were given in response to that report which again focused on discharge without family/carer involvement which is surely paramount. I note actions mentioned in the incident report in this case but am still concerned that similar events may occur in future.