Alison Jane DRAPER · Prevention of Future Deaths report

On 10th September 2014 an investigation into the death of Alison Jane DRAPER, Aged 45 commenced. The investigation concluded at the end of the inquest on 28th May 2015.
The conclusion of the inquest was:

Medical Cause of Death
Ia Hypoxic brain injury
Ib Neck ligature
Ic Mental health issues

Conclusion – Narrative

Alison Draper was found ligatured in her bedroom whilst a patient on Juniper Ward, she died from the injuries she sustained, her intention is unknown. She was on 10 minute observations at the time and should have been checked at 7pm she was not found in her bedroom until approximately 7.12 pm which was 20 minutes approximately from the previous check; this resulted in a lost opportunity to render medical care, attention or treatment.

Ms. Draper had a history of mental health problems over a number years which included several attempts to self-harm and take her life.

On 8th August 2014 she was admitted to Elizabeth Casson House at Callington Road Hospital, she was detained under Section 2 of the Mental Health Act.

During this admission she made 8 attempts to take her life by ligature. The risk of self-harm/suicide was described by her Consultant. ████████ as being chronic and impulsive.

On 5th September 2014 Ms. Draper was stepped down from the Psychiatric Intensive Care unit to Juniper Ward (an open acute unit).

On 7th September a Health Care Assistant was tasked with carrying out 10 minutes observations on Ms. Draper. She last observed her at 18:50 in the garden.

At the 7pm check the same Health Care Assistant was also tasked with carrying out the hourly checks for all 19 patients on the ward, two of whom were on 10 minute observations, one of whom was Ms. Draper.

It is unclear how the checks were actually carried out as the witness could not remember but at approximately 7:10/7:12 pm she asked for assistance from two other members of staff. Ms Draper was found in her own bedroom having ligatured herself.

Ms. Draper was taken to Hospital but suffered an un-survivable hypoxic brain injury

1. I heard evidence that there is no policy in relation to what staff should do if a patient/service user is not found within the 10 minute observation period. I would ask that you consider whether guidance should be issued as to the steps that staff should take.

2. I would also request that you consider the hourly check as detailed above. It appears in this case that one member of staff was asked to check 19 patients, two of whom were on 10 minute observations. Please consider whether guidance be given as to how to manage and balance the hourly checks with those on 10 minute observations.