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Investigation and inquest
On 21/03/2016 I commenced an investigation into the death of Wendy Louise Telfer, 44 . The investigation concluded at the end of the inquest on 12 January 2017. The conclusion of the inquest was accidental death.
The medical cause of death was recorded as
1a Liver Failure
1b Overdose of Paracetamol
2 Asthma
Circumstances of the death
Wendy died on 20 March 2016 in the Royal Devon and Exeter Hospital from an overdose of purchased non-prescribed medication she had taken 5 days earlier. On the balance of probabilities, had she received appropriate care during her in patient stay between 11 – 15 March, this opportunity to self-harm would have been avoided. Opportunities were missed to keep Wendy safe.
Coroner’s concerns
(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve", although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment, which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
Information checked against the published report and official responses