Rosalind Flett · Prevention of Future Deaths report

On 21st February 2017 I commenced an investigation into the death of Rosalind Flett
The investigation concluded at the end of the inquest on 18th April 2018
The cause of Miss Flett’s death was due to an incised right internal jugular vein. The jury recorded a narrative conclusion:
On 11th February 2017 Rosalind Flett was detained under section 2 of the Mental Health Act presenting with emotionally unstable personality disorder and a history of deliberate self harm, at Gresham 1 ward Bethlem Royal Hospital, Beckenham
At the time Miss Flett was subject to enhanced arms length observation with thrice daily room and personal searches.
However, these measures were not effective in locating any razor blades in spite of five previous incidents of cutting between 27th January and 8th February 2017.
Sometime between midnight and 0100 whilst standing in the common area with the two nursing staff, Miss Flett ran away along the corridor, stopped and using a razor blade to make a deep laceration in her neck in full view of a third nurse.
Miss Flett was transferred to king’s College Hospital, Camberwell, but died shortly thereafter.

Ms Flett cut her neck with a razor blade in full view of nursing staff. During her hospital admission she had regularly concealed razor blades in a variety of places, on at least one occasion was known to conceal a blade in her bra. It is not known where she concealed the blade that she used to fatally cut her neck.

The Trust’s policy on searching was made in accordance with the Mental Health Act 1983 Code of Practice. However, there appeared to be a gap between “an advanced search” which was limited to a pat down of clothing and did not allow for clothing to be removed to underwear, and an “intimate search” which deals with items concealed in a body orifice. Staff were therefore given the impression that they could not ask Ms Flett to remove her bra for searching.
Since the conclusion of the inquest I have been informed that the local Trust search policy is to be amended. However, the ambiguity appears to exist in other Trust policies, and I therefore make this report in order to bring the matter to wider attention.