Woman drowned in park pool amid ‘manic episode’
Discharged by psychiatrist just days before
ACORONER said there were failings in the care of a mother who drowned in a lake during a mental health episode.
Ann Mohan, 53, thought she was a child again and her dead dog had come back to life when she entered the pool at Pype Hayes Park in Castle Vale in September last year, an inquest heard.
Despite being terrified of water, witnesses at the busy park saw the mum-of-three ‘enjoying a swim’ and ‘swishing her hair around’.
Minutes later she was face down in the lake showing no signs of life. Ms Mohan, who suffered from bipolar affective disorder, was pulled from the water but never regained consciousness.
She later died at Heartlands Hospital.
Only days before she was discharged during a three-minute ‘assessment’ over the phone with her psychiatrist, the inquest heard.
It was told the phone call review had not been ‘appropriately conducted’ and was the root cause failing in Ms Mohan’s care by Birmingham and Solihull mental health trust.
Area Coroner Emma Brown concluded Ms Mohan died following dangerous action taken while suffering a manic episode contributed to by failings in mental health care.
Ms Brown said: “It is my conclusion that it was not her intention to end her life. She acted as a result of her manic episode.
“I accept that she had never spoken of suicide.
“Her family were her safety net. There was no evidence of deliberate planning. Ann should not have been discharged.”
The Coroner said she should have undergone a full assessment as had been planned but Ms Mohan would not engage with a full assessment.
“I accept the finding of investigation that Ann should have been placed on the care plan approach. There were failings in her care.
“There clearly were a number of missed opportunities to assess the gravity of the relapse.
“While she ought to have been given more support and ought to have received support, I accept she was not presenting to be an immediate risk of death.”
The inquest heard how Ms Mohan had been sectioned over a depressive episode a year before in September 2019, and she was ‘struggling with daily life’ in the months that followed.
It was told that Ms Mohan, from Erdington, had told psychiatrist Dr Annie Simon she had been using cannabis for 27 years.
Dr Simon said: “I was very clear that she needed to avoid using cannabis. Ann said she did not think it was a problem.
“I explained that cannabis can trigger these episodes.
“There was a note that before her episode she had been smoking a lot of it.”
Days before the park incident Dr Simon called Ms Mohan for a review of her care. Dr Simon told the inquest she felt Ms Mohan had the ‘capacity’ to be discharged from the phone call.
“She was very
clear
that she would get back to us if she had any concerns and her family would do that as well,” she said.
“She was very adamant and very rational and I clearly felt she had the capacity to do so.
“If a patient has full capacity it gives them the right to decide on treatment.”
Three days later, she was suffering from delusions her dead dog had come back to life. She also believed her ex-partner was coming back.
Her son, Adam, called Dr Simon, Ms Mohan’s GP and a social worker and an urgent referral was made to see her the same day.
Dr Simon said: “I referred her to the home treatment team urgently. My opinion was that Ann was showing signs of another manic episode and I recommended she be seen on the same day.”
However, the inquest heard the home treatment team did not arrive until the following day. During the morning visit, Ms Mohan would not engage with the team and refused to allow them into her property unless they removed their PPE.
They had a brief discussion through the window instead before Ms Mohan shut the window and sat back down on the sofa to watch TV. The team decided she was suffering from a relapse, but she was not deemed a risk to herself or others. A plan was made to recommence medication and ‘intense’ home treatment going forward.
Mr Patrick Cullen, a registered mental health nurse, conducted a review of Ms Mohan’s care and told the inquest he found ‘missed opportunities’ in her care.