Death of 29-year-old woman with long history of mental health issues at Derbyshire hospital could not have been prevented, inquest finds

Sandra Woods, 29, sadly passed away at the Field House clinic on Chesterfield Road, Alfreton on August 30 2020.

During an inquest held on Friday, September 23 at Chesterfield Coroner’s Court, Area Coroner Peter Nieto said that Sandra had a “history of mental health problems” which went back to her teenage years.

Mr Nieto said that Sandra, who was originally from Wigan, suffered from emotional unstable personality disorder and a degree of learning disability. He added that she had been sexually abused by a close family member in her childhood, which he said was “undoubtedly a key factor in the development of her mental health difficulties.”

The court heard that Sandra’s mood could be volatile, and although there were instances of violence towards others, her behaviour largely posed a risk to herself – with a number of incidents involving self-harm. Other than for a period of around four months, Sandra was detained continuously under the Mental Health Act between 2014 and her death.

In 2018, the low security unit where Sandra was receiving treatment was closed down. The Wigan Borough Clinical Commissioning Group looked for suitable alternative placements, but the court heard that these are few in number, and may not be close to the patients home.

Field House in Alfreton was newly opened and assessed as appropriate for Sandra, and she moved there in July of that year, despite the distance from Wigan and her mother. The facility is a private sector mental health hospital, operated by Elysium Healthcare, which specialises in treating women diagnosed with personality disorders.

At the facility, Sandra had restricted and supervised access to items which she could use to self-harm, along with regular checks of herself and her bedroom. Staff conducted four observation checks of Sandra every hour.

The mental health nurse and social worker who were assigned to Sandra in Wigan were also kept updated with regards to her progress and treatment, and Sandra kept in touch with them herself.

Mr Nieto said that Sandra’s mental state initially improved at Field House, and in November 2019 she became a voluntary patient. After a series of high-risk incidents, however, she was reassessed, and detained again under the Mental Health Act in February 2020.

After this, the frequency and intensity of Sandra’s self-harm incidents increased. Mr Nieto said that she also developed romantic feelings towards staff, which caused her additional stress. Staff evaluated the viability of her placement and decided that her treatment should continue, but her condition did not improve.

In the weeks before her death, Sandra was assessed as being at high risk of self-harm. She had expressed to multiple professionals that she did not self-harm with the aim of causing her death, and that she expected staff to find her before her condition became critical. Mr Nieto added that people with her condition often use self-harm as a means of “emotional self-regulation” and communicating their distress.

On August 8, the Care Quality Commission undertook a review of the provision at Field House, and issued a warning notice to Elysium Healthcare on August 28.

Following Sandra’s death, the CQC made further inspections, and the facility remained under special measures until June 2021, when all concerns raised by the CQC were rectified.

On August 18 2020, a consultant psychologist sent an email to Sandra’s social worker and mental health nurse in Wigan, in which he said that continuing her placement was not appropriate, and that she needed a setting more specialised in dealing with self-harm.

A visit was planned for September 23, but 11 days later, the psychologist contacted them again and said that Sandra’s condition had worsened, and that they could not wait until their planned September visit.

The Wigan CCG looked for alternative placements for Sandra, but none that suited her needs were immediately available.

On August 29 2020, Sandra had become distressed and banged her head against a wall. After calming down, she asked a member of staff at 11.50pm to use the toilet in her bedroom. Before going in, this nurse checked that her cupboards were locked and that she had nothing in her pockets.

At midnight, the head nurse on shift was showing an agency worker around the unit, after they had arrived to cover for a member of staff who had not turned up. Between 12.15am and 12.20am he checked on Sandra, and found her unresponsive on her bedroom floor.

He activated the emergency alarm and began CPR. A 999 call was logged at 12.39am and staff attempted to resuscitate Sandra using a defibrillator – but no shockable cardiac activity was detected.

Paramedics arrived on the scene at 12.57am and Sandra was officially declared dead at 2.54am. After carrying out a post-mortem, a pathologist stated that Sandra’s cause of death was the application of a ligature around her neck.

In his conclusion, Mr Nieto said there were two issues to consider – the first being whether Field House was appropriate and safe for Sandra by the time of her death.

He said that staff had conveyed the need for an alternative placement, but Sandra’s situation was not considered so dire that she needed to be removed to an acute unit immediately. He added that the CCG had made swift enquiries to find another placement, but none were readily identifiable.

Mr Nieto also said that the evidence presented in court showed that observing Sandra four times every hour was sufficient. He said that “one-to-one observations would have been intrusive” and likely counter-productive in terms of reducing self-harm.

Mr Nieto also questioned whether the delay in making the 999 call had contributed to Sandra’s death. The automated system for logging calls said that it came through at 12.39am – and if Sandra was found between 12.15am and 12.20am, that could have been as long as 24 minutes after she was first discovered. Mr Nieto did, however, accept that the time Sandra was found may not have been exact.

He added that, even if the call was made earlier, it still would have taken paramedics 18 minutes to arrive. The staff who gave Sandra CPR had enhanced training, so there was no reason to believe this was ineffective.

The defibrillator did not detect a shockable cardiac rhythm, and the doctor who performed Sandra’s post-mortem said that application of pressure to the neck can result in irreversible brain injury in just a few minutes.

Concluding, Mr Nieto said that there was “no evidential basis to find these matters contributory to Sandra’s death”, or that Sandra had intended to take her own life.

He said that Sandra probably had hundreds of self-harm incidents, and clearly expressed that these were not intended to cause her own death. She did not state to anyone that she intended to take her own life in the build-up to this incident, and left no note or any messages that could be interpreted as a farewell.

After deliberating, the jury reached their verdict. They did not find that any of the issues raised had contributed to Sandra’s death, and stated that there “was no evidence to support that Sandra intended to cause her own death.”