Woman who died after drinking excess water suffered ‘failings in care’
A woman who suffered a heart attack at a private mental health hospital due to complications from drinking excessive amounts of water experienced “gross failings in her care amounting to neglect”, an inquest jury has found.
Lillian Lucas, 28, known as Lily to her family and friends, died in 2022 after being found unresponsive in her room in the Milton ward of Cygnet hospital, near Weston-super-Mare, Somerset, where she had been an inpatient since June.
An inquest jury at Avon coroner’s court found yesterday that opportunities had been missed by staff to render care which would have prevented Lucas’s death including a failure to monitor her worsening condition and inadequate response to it.
Lucas, who lived in Malmesbury, Wiltshire, was a mental health nurse who had previously been diagnosed with schizophrenia and had been admitted to various hospitals numerous times in the years before her death, the inquest heard.
On 8 September 2022, after drinking “excessive amounts of water”, she was found unresponsive in her room and transferred to Bristol Royal Infirmary, the jury heard. She died the following day.
Postmortems found she died of a heart attack and the impact of psychogenic polydipsia, when due to a mental disorder a person experiences an uncontrollable urge to drink water.
The jury at Avon coroner’s court concluded yesterday that “there were gross failings in her care amounting to neglect”. In the record of the inquest, the jury said the Milton ward was “understaffed at a level deemed to be unsafe”.
The jury added: “Lily was observed to be drinking excessively from approximately midday and staff attempts to stop her were inadequate.
Lily’s mental and physical health deteriorated throughout the afternoon with staff failing to document Lily’s condition according to hospital policy. There was a failure to recognise the psychogenic polydipsia and that continued excessive drinking could cause serious harm or death.
“Opportunities were missed to render care which would have prevented Lily’s death.”
The coroner Dr Peter Harrowing said he had decided not to file a prevention of future deaths report because he was satisfied Cygnet had acted to address concerns including staffing levels at the hospital.
A doctor who had previously treated Lucas spoke earlier in the eight-day inquest about the possible reasons why someone would drink excessive amounts of water.
Dr James McIntyre, a consultant psychiatrist who had treated Lucas before her admission to the Cygnet, said psychogenic polydipsia could be caused by the side-effects of anti-psychotic medication or as a symptom of the psychosis itself.
On 5 September, as her condition deteriorated, the inquest heard Lucas was prescribed clozapine.
“Lily had always feared being prescribed clozapine,” Lucas’s mother, Mary Curran, said in her statement. “Lily was aware of the possibility of severe side-effects.”
On the opening day of the inquest, Curran read a pen portrait of her daughter, who graduated from the University of the West of England in 2017 as a mental health nurse. “Lily was beautiful, loving, generous and hilarious,” she said. “She was so carefree and fun, and so full of mischief.”
A Cygnet spokesperson said: “We take our responsibilities to provide safe care extremely seriously,” adding: “All nursing staff at Cygnet Hospital Kewstoke have undergone additional training and we have employed a full-time physical health lead who works across the hospital to enhance the skillset of our staff team.”