Failures to record an inpatient’s suicide attempts on a ‘risk assessment’ log were partly to blame for her death days later at a Northampton Hospital - a coroner has ruled.
Isobel Griffin, 56, of Daniell Walk, in Corby, was found hanged in the bedroom of a ward at Berrywood Hospital on August 17, 2013.
She had used a dressing gown cord, which she tied to a jumper and attached to the door of her room.
At the conclusion of a two-day inquest yesterday, deputy coroner Belinda Cheney returned a verdict of suicide - but added that ‘inconsistencies’ and ‘difficulties’ in her healthcare had contributed to a decline in a long-running psychological condition, which started after the birth of her second child in 1980.
Among many criticisms, the coroner said staff at Berrywood did not class Mrs Griffin as a ‘ligature risk’, despite the fact she had told staff she wanted to die on numerous occasions.
Mrs Cheney said: “What was apparent was that the risk assessments were little more than a tick-box exercise - copied and pasted over from one day to the next with very little amendment.”
Mrs Griffin, whose life was said to have ‘unravelled’ in 2011 after the death of a friend, was admitted to Berrywood on August 1.
She had recently gone missing from her home in Corby and was found days later ‘under a bush’, her husband Jim told the inquest, having taken a drugs overdose.
During yesterday’s hearing professor Kevin Gournay, the consultant psychologist who compiled a lengthy report into the history of Mrs Griffin’s care, raised a number of concerns about her treatment at Berrywood.
The expert was particularly critical of the way her risk assessment was not updated following an incident on August 7, in which Mrs Griffin handed over a belt and scissors to a hospital nurse for her own safety, admitting that she had tried to take her own life on four previous occasions.
He said: “This was not an isolated incident - it should have triggered a thorough risk assessment of her.”
Had staff classed her as a ‘ligature risk’, dangerous items such as shoe laces, belts and dressing gowns would have been removed from her bedroom as she could have used them to hang herself. Staff would have also checked her room at regular intervals.
Mr Gourney said numerous healthcare officials made notes that showed Mrs Griffin expressing an intention to kill herself - yet these were not entered into the risk assessment log, which is normally used to inform on-shift staff of a patient’s current condition.
“By the time we get to the seventh of August we get a really clear context of someone who is suicidal,” Professor Gournay said.
And the expert raised further questions as to how a ligature could be tied to a hospital ward door.
Professor Gourney said after looking at a photograph of the doors: “There are at least four companies that supply the NHS with anti-ligature doors,” he added.
Yesterday Mr Patino said investigations are ongoing as to how to reduce the hanging risks in the ward bedrooms.
He also said the hospital is carrying out a review of how it updates its risk assessment logs.