Emily Katherine Inglis · Prevention of Future Deaths report

On 22 April 2016, Emily Katherine Inglis was found deceased in her bedroom on the Bryngofal Ward at Prince Philip Hospital, Llanelli, with a plastic bag over her head. At the time of her death she was detained under the provisions of the Mental Health Act. A post-mortem examination report provided a cause of death as plastic bag asphyxia.

On 27th April 2016 I commenced an investigation into the death of Emily Katherine Inglis. The investigation concluded at the end of the inquest on 15th April 2019. The conclusion reached by the jury was one of misadventure.

(1) Emily Katherine Inglis was born on 9 June 1989 and was 26 years of age at the time of her death. She had a history of mental health illness and at the time of her final admission to hospital in December 2015 suffered from a borderline personality disorder.
(2) The inquest considered, inter alia, the risk assessments undertaken, the record-keeping and the suitability of an acute psychiatric inpatient unit to treat patients with borderline personality disorder.

(1) The inquest identified that there should have been an overarching risk management plan in place to assist medical professionals and staff in treating and caring for Emily.
(2) The inquest further identified that there were deficiencies in record-keeping, both in terms of ensuring that risk management strategies remained up-to-date and in preserving handover records.