Police didn’t join search for patient who walked out of mental health hospital and was found dead the next day – inquest
SHE WAS ONLY WEARING SLIPPERS, NIGHTDRESS AND GILET WHEN SHE ESCAPED FROM SECURE UNIT INTO THE COLD OF CHRISTMAS NIGHT
POLICE did not join the search for a woman on the night she walked out of a secure mental health ward in Nottinghamshire, an inquest has heard.
Helen Tarry’s body was discovered on a farm track near Calverton on Boxing Day in 2022, the morning after leaving the Priory Hospital Arnold.
An inquest into her death yesterday, heard that Nottinghamshire Police received numerous calls from staff but did not deploy officers due to a lack of resources.
Nottingham Council House was also told the nurse in charge of Ms Tarry’s ward was unaware that she was at risk of walking out.
The 52-year-old, who was being treated on the secure Bestwood ward, tailgated a staff member through two doors before pressing a fire alarm and running outside into the car park at 10.18pm on Christmas night.
Wearing only a gilet, nightdress and slippers, Ms Tarry faced temperatures as low as 2C through the night before her body was found off George’s Lane at 8.30am.
On Thursday, her partner Howard Mather had told the inquest he was “extremely concerned” she was able to abscond without being seen.
Giving evidence yesterday, Kaja Ksiakiewicz, the nurse in charge of the night shift, said she was not made aware of Ms Tarry’s risk of absconding or the fact she had tried to leave earlier.
The nurse said she would have increased how often Ms Tarry was observed had she been aware.
“The need to understand people’s risks are of utmost importance to keep people safe, is that right?” asked assistant coroner Fiona Gingell. “Of course ma’am,” responded the nurse.
Ms Tarry’s risk was neither mentioned on handover notes nor her online records, but was written on a whiteboard in a staff room, the inquest heard.
Inconsistencies in how often she should be observed were also found in her records.
The nurse handing over to Ms Ksiakiewicz at 7.30pm advised Ms Tarry should be checked on once every 15 minutes, however this was not reflected by the online or whiteboard notes, which said once every hour.
The inquest also heard that staff were expected to ring a doorbell when moving between wards, something Ms Gingell pointed out appeared not to happen when Ms Tarry closely followed a staff member.
“I was assured staff working under me would not be going to other wards because they had other responsibilities to attend to,” added Ms Ksiakiewicz.
“I would expect staff members to come to me to seek permission.” After more than half-an-hour of searching for Ms Tarry after she left, staff called for police assistance.
They initially told the force she was at a low risk but made a followup call when they became more concerned.
I was hoping for them to come out and support us,” said Ms Ksiakiewicz. “Even if we did come across Helen, by protocol we wouldn’t be able to let her into the vehicle or restrain her, it would require police input.
“They told me resources were limited, I contacted them again wanting a welfare check and I was told the same thing.”
In a statement read out at Nottingham Council House on Thursday, Mr Mather said he “fell apart” after his partner’s body was found by a dog walker off George’s Lane.
“I couldn’t process it, her death has created a huge void in my life,” he said.
Mr Mather, who had been planning to marry Ms Tarry after almost 10 years together, told the jury inquest how his partner had become “increasingly paranoid” throughout November and December of that year.
He said the pandemic and the recent death of her dad had further impacted her mental health.
He described how Ms Tarry, a system support officer for Nottinghamshire County Council, had started to shred paperwork and hide items around their house before eventually moving in with her mum. She also became convinced her phone had been hacked and called police on several occasions. “On December 7, she tried to run away from her mum’s house with her laptop. She believed it had been hacked,” said Mr Mather, who added that police later found her at a golf course. Feeling the situation had reached a “tipping point”, Mr Mather said Ms Tarry saw a mental health crisis team, which began plans for her to go to Highbury Hospital.
After spending the night at home “staring out the front window” and calling the police on several occasions, Ms Tarry attempted to run away again on December 9. She was later taken to King’s Mill Hospital after taking an overdose of paracetamol and was voluntarily referred to the Priory Hospital.
Mr Mather recalled his partner looking “angry and tense” when he visited her two days later.
“I was devastated by how much her symptoms had worsened,” he said. “Staff thought I could be a trigger and advised me not to visit for a while.”
Ms Tarry was sectioned under the Mental Health Act on December 13 and moved to the secure Bestwood ward.
Mr Mather said the last time he saw her, on Christmas Day, she asked him to help her leave.
“She seemed to be in a panicked and anxious state,” he recalled. “She wasn’t sure who I was but asked me to take her out of the hospital.”
When learning she had left, he quickly returned to join the search at the hospital, where he said he was told that patients often walked out and then return, by one member of staff.
“I walked through the woods with a torch shouting Helen’s name, it was dark, cold and I was scared,” he said. Upon rejoining the search the next day he was told Ms Tarry’s body had been found at 8.30am.
Professor Guy Rutty, a forensic pathologist, could not find a clear cause of death but said the “most obvious given the circumstances” was hypothermia.
After being told that Ms Tarry had suffered badly from asthma by her mum, Ann, Professor Rutty said he also “could not exclude a coldinduced asthma attack”.
The professor also identified scratches on Ms Tarry’s limbs, likely caused by vegetation, as well as foreign objects such as bottle lids and checkers or chess pieces in her stomach and intestines.
He said none of these could have contributed to her death.
Detective inspector Mark Booth said it was “very cold” outside, and referred to a report by the Met Office which showed temperatures had stayed between 2C and 8C overnight.
He said Ms Tarry was found with no gilet or slippers, adding only one slipper had been found further down the track.
The inquest was shown CCTV footage from the night Ms Tarry left the hospital.
A clip from earlier in the day showed staff holding her back as she moved towards the ward’s exit.
Footage showed Ms Tarry then closely following a member of staff through two doors, at least one of which was secure, before activating a fire alarm and walking through to reception and into the car park.
The inquest continues.
They told me resources were limited; I contacted them again wanting a welfare check and I was told the same thing
Kaja Ksiakiewicz