Omissions in care likely contributed to death of Sarah Adams, coroner rules
A woman from Reading took her own life after being discharged from a specialist mental hospital without a care plan, an inquest has heard.
Sarah Adams, who was described as a fun-loving lady, suffered from paranoid schizophrenia.
In September 2021 her health began deteriorating and when she was ill, Sarah spent a month under the care of the mental health crisis team before being released into community care.
Later, her health worsened again, and she was admitted to the Cygnet Harrow Hospital after making an attempt on her life.
It was issues relating to her discharge from there that a coroner in Reading said most likely contributed towards her death.
When she left the hospital, she was anxious about who would care for her. She left with a large amount of medication and a visit that she was expecting from the crisis care team didn't materialise.
The coroner said it was likely that she felt out of control and the following day she was found dead.
The coroner delivered a narrative conclusion finding that Sarah had taken her own life, but the omissions in her care on discharge from Cygnet Harrow Hospital have most likely contributed to her death.
Sarah's niece, Izzy Adams, today told ITV Meridian what happened to her was heartbreaking and horrendous. She said: “It's heartbreaking. You know, anyone with, you know, mental illness, you, you know it's not day by day, it's different.
“Every day is a different day. Um, and obviously when she's bad, the days were horrendous, painful to see. You know, someone suffering like that, it's just horrendous, and you don't wish it on anyone.”
Izzy Adams speaks to ITV Meridian after the inquest.
A Cygnet spokesperson said: “We would like to express our deepest condolences to Sarah’s family and all those who continue to be affected by her loss.
“We take our responsibilities to provide safe care extremely seriously. We always seek to ensure lessons learned are identified and shared, and we are committed to working together with other organisations and partners across mental health services.
“Where areas for improvement have been identified at Cygnet Hospital Harrow, we have been working hard to address them. For example, we have new leadership in place at the service, including a new hospital manager, who is overseeing positive changes. We have strengthened governance processes at the hospital, reviewed elements of our discharge policy, and increased investment to renovate the ward environments and enhance service user experience.
“Service user care will always be at the heart of what we do, and we are hopeful that the upcoming CQC inspection report for Cygnet Hospital Harrow will highlight the improvements we have embedded.”
If you have been impacted by any of the issues raised, support is available.
CALM, the Campaign Against Living Miserably, runs a free and confidential helpline and web chat. It also supports those bereaved by suicide, through the Support After Suicide Partnership (SASP). Call 0800 585858 (daily, 5pm to midnight).
Mind is a mental health charity which promotes the views and needs of people with mental health issues. It provides advice and support to empower anyone experiencing a mental health problem, and campaigns to improve services, raise awareness and promote understanding. Call 0300 123 3393 or email info@mind.org.uk
PAPYRUS aims to reduce the number of young people who take their own lives by breaking down the stigma around suicide and equipping people with the skills to recognise and respond to suicidal behaviour. It provides practical, confidential suicide prevention help and advice over telephone, text and email service which is staffed by trained professionals. Call 0800 068 4141, text 07860 039967 or email pat@papyrus-uk.org.
Samaritans is an organisation offering confidential support for people experiencing feelings of distress or despair. Phone 116 123 (a free 24-hour helpline) or email jo@samaritans.org
YoungMinds is a resource with information on child and adolescent mental health, but also offers services for parents and professionals. It is the UK’s leading charity fighting for children and young people's mental health, and wants to make sure all young people can get the mental health support they need when they need it. Visit youngminds.org.uk
Shout is a 24/7 text service, free on all major mobile networks, for anyone struggling to cope and in need of immediate help. Text SHOUT to 85258.
SOS Silence of Suicide provides a listening service for children and adults who require emotional support, understanding, compassion & kindness. Phone 0300 102 0505