Investigation and inquest
On 9 November 2016 I commenced an investigation into the death of Sabrina Michelle Walsh, aged 32. The investigation concluded at the end of the inquest on 6 July 2017. The conclusion of the inquest was that Sabrina Walsh deliberately chose to attach a ligature to herself but the evidence does not fully explain whether or not she intended that the outcome be fatal. This was contributed to by neglect.
Circumstances of the death
The deceased was detained under the Mental Health Act as a patient in Woodlands Acute Care on 31 October 2016. She was found hanging with a ligature around her neck which had been slotted over the door through the closure. Sabrina deliberately tied and applied the ligature to herself. The lack of formal assessment had direct impact on Sabrina as if she had a risk assessment she would have been on correct observations thereby reducing the risk of self harm.
The staff at Woodlands did not effectively appreciate the needs of Sabrina, which resulted in a serious failure of her care. If they had followed procedure and placed her on one to one observations this would have greatly reduced the opportunities to harm herself.
Overall if correct procedures were followed they would have had a positive effect on Sabrina and the level of care received.
By not following procedures this has had a clear and direct effect on her passing. This is a gross failing of medical care from staff at the Woodlands.
Coroner’s concerns
The lack of CCTV in corridors and communal areas at Woodlands Acute Care, St Leonards on Sea, which would enhance location of vulnerable patients where observations do not immediately locate them. Valuable minutes would be saved in locating vulnerable patients if CCTV was installed.