Helen Louise MILLARD · Prevention of Future Deaths report

On 14/05/2015 I commenced an investigation into the death of Helen Louise MILLARD. The investigation concluded at the end of the inquest 26th September 2016. The conclusion of the inquest was Accidental Death.

At between 18.32 & 18.59 on the 12th May 2015, the deceased hanged herself using the taps in a bathroom at the Westlands Mental Health Unit, Hull. She died at the Hull Royal Infirmary at 01.28 on the 13th May 2015.

Evidence was heard that NHS England is undertaking an ongoing programme of work to eliminate ligature points in in-patient and other psychiatric facilities. It was established that a ‘traffic light’ system is in operation which prioritises the work once a ligature point has been identified in any particular facility. The Court heard that if a point is scored ‘red’ this equates with an extreme risk and mandates urgent elimination of the point. If, however, a risk is categorised as ‘amber’ this nevertheless represents a high risk. The classification according to this traffic light system is based upon the height of the ligature point from the ground. If a ligature point is one metre or less it is categorised as being ‘amber’, whereas if it is over one metre above the ground it is categorised as ‘red’.

Expert evidence was adduced from a number of expert witnesses and Consultant Psychiatrists that at least 50% of deaths due to hanging in inpatient psychiatric facilities occur from ligature points which are one metre or less in height above the ground. Patients merely need to learn forward and tighten the ligature around their neck under their body weight and they collapse into unconsciousness within ten to twenty seconds and death can occur in as little as two to three minutes. This evidence was backed up by peer reviewed literature which was also read out during the course of the Inquest.

My principal concern is that there is an obvious incongruity in the classification system as effectively all ligature points, no matter what their height, should be regarded as representing extreme risks. Evidence was heard that the risk is independent of height and consideration needs to be given to classifying all ligature points once identified as ‘red’ and their elimination tackled on an urgent basis.