Coroner’s concerns over woman’s suicide

HIGH-RISK PATIENT ‘SHOULD HAVE BEEN SEEN MORE QUICKLY’ BY TEAM

A CORONER expressed concerns over the care of a high-risk patient who went on to take her own life.

Joanna Swann, 37, suffered from severe depression and psychosis and at the time of her death was living in a flat in Reddish, Stockport, under the management of Pennine Care NHS Trust’s early intervention team.

Joanna was found dead on September 21, 2015, after her care co-ordinator Lucy Beck called police when she was unable to get hold of her.

The cause of Joanna’s death was recorded as helium toxicity and a ‘note of intent’ addressed to her parents was found in the flat.

Recording a verdict of suicide, Assistant Coroner for South Manchester Anna Morris said: “I am satisfied that she took her own life, and that she intended to die.”

The court heard that on September 15, almost a week before she was found dead, Joanna was discovered at home by her mother with a ligature around her neck. She had previously admitted to Ms Beck that she had attempted to hang herself.

On September 14 there was a meeting between those handling Joanna’s care at which she was placed in the ‘red zone,’ meaning she was at a high risk of harming herself – however, she was not due to be seen again until the 21st, and her care plan was not updated.

It was also said that, at the time, Ms Beck had not undergone the STORM (self harm mitigation) training that care co-ordinators are required to have.

Giving evidence at the inquest, Christina Murray, manager of the early intervention team who carried out an internal investigation review for Pennine, said some changes have since been made. Meetings about patients’ care now take place daily rather than weekly, and the team has a dedicated psychiatric consultant.

Joanna’s family described her as an ‘extremely caring, sensitive and empathetic person.’

Ms Morris said: “I am concerned that between September 12 and 21 no contact was made between the early intervention team and Joanna. Given that she was deemed to be at risk I think she should have been seen more quickly. I am also concerned that despite her being placed in the red zone her care plan was not updated, and that the care co-ordinator had not had the STORM training.

“I will be writing to the trust as I feel there is learning that can be taken back on those three topics.”