Nicola Matthews · Prevention of Future Deaths report

At the time of Nicola’s death I opened an inquest. The inquest concluded on 14th August 2013. A copy of the Record of the Inquest is attached. Your Trust was represented at the hearing by ████████ of Bevan Brittan, solicitors. The family was represented by counsel, ████████

As set out on the record of the inquest:

Nicola Matthews had a long history of borderline personality disorder. She had performed many acts of self-harm, necessitating a number of hospital admissions. On 12 October 2010 she took an overdose of drugs and was admitted to hospital, where she was detained under section 5 of the Mental Health Act. This detention was rescinded by her responsible medical officer on 15th October. Nicola wished to be allowed to leave hospital and was permitted to do so on the understanding that her partner would accommodate her. There was a lack of clarity about the follow-up arrangements but this probably was not causative of her subsequent consumption of drugs at her partner’s home later that evening. Her partner woke from sleep at about 01.30h on 16 October to find Nicola unrousable. She was conveyed by ambulance to hospital where she was pronounced dead. Her intentions are not clear beyond reasonable doubt and her actions were probably not accidental.

My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round. Nicola had a long-standing history of borderline personality disorder and was constantly at risk of self-harm. Her acts were frequently impulsive. Whilst she had been sectioned on 12 October, the Section 5 order was rescinded on 15 October at the ward round. Nicola was then insistent on being allowed to leave the hospital.

The follow-up arrangements made for her continuing care were not clear and were not documented. Evidence at my inquest suggested that there was no clarity as to what the follow-up arrangements were and whether or not they were made clear either to Nicola or to her partner.

In the event, Nicola went home and later that evening took an overdose of medication which resulted in her death. Whilst it is not possible to state that better arrangements for follow-up would probably have made a difference to the outcome, I am concerned to ensure that in future patients who are discharged have a clear understanding of follow-up arrangements. It is important that staff members on the ward who have to handle the departure of the patient from the ward have clarity as to what is to happen. In the case of Nicola, with the period of time between the decision being made and her actually leaving, staff had changed and the contemporaneous documents did not allow the member of staff who escorted Nicola off the ward to have a clear understanding of follow-up arrangements or indeed of the nature of and quantity of medication with which she was being discharged.

I suggest that consideration should be given to formulating better advice and ensuring that important decisions are better documented and that follow-up arrangements are made clear and adequately documented.