Redcar woman died hours after absconding from mental health hospital
An inquest has heard a Redcar woman was found dead at the bottom of cliffs in Saltburn hours after absconding from a mental health hospital.
57-year-old Pamela Brown died on 20 September 2019, two weeks after being sectioned under the mental health act at Roseberry Park Hospital in Middlesbrough.
A jury heard she left the site after being allowed to go on 10-minute unescorted leave in the grounds of the hospital.
Mrs Brown’s body was found later that evening at the bottom of Huntcliff in Saltburn.
The inquest at Teesside Coroners Court heard Pamela Brown - who worked part time at the Department for Work and Pensions - had a history of depression and anxiety.
In 2019, she weened herself off medication but six months later went back on them after her anxiety worsened and she struggled to sleep.
On 5 August 2019, the jury were told Mrs Brown had been referred into the care of the Tees Esk and Wear Valleys NHS Foundation Trust crisis community team after overdosing on sleeping tablets whilst staying with her sister.
On 15 August she was admitted to Roseberry Park Hospital in Middlesbrough after being found by her daughter walking near a busy road in her dressing gown.
She agreed to go for Roseberry Park for treatment as a voluntary patient.
Over the following three weeks there were a number of serious incidents that would lead to Mrs Brown being detained under the mental health act.
Timeline:
25 August 2019 – Pamela Brown was allowed leave from the hospital to stay with family but had been unable to sleep and had suicidal thoughts so returned to Roseberry Park the following morning. That same day she was found to have ingested eye cleaning fluid.
31 August - Left the hospital grounds after telling staff she was going outside to read a book. Pamela was seen on CCTV throwing the book in the bin and later that day was found at Morpeth railway station.
2 September - Granted leave from hospital to stay with her family. During that time she drank some disinfectant fluid and was taken to A and E at the James Cook University Hospital before going back to Roseberry Park.
6 September - Detained under the Mental Health Act.
20 September 2019 - Runs away from hospital while on an authorised unescorted leave. She is found dead that evening.
On 16 September, the inquest heard, it was agreed Mrs Brown would be able to start having unescorted leave in the hospital grounds and when she visited occupational therapy.
On the 20 September at 12.40pm she told staff she would like to go for a walk and was granted 10-minutes unescorted leave within the grounds of Roseberry Park.
The inquest heard Mrs Brown was assessed by a member of staff regarding her safety before the leave was granted and there was no evidence of distress.
The inquest heard Pamela Brown was due to return at 12.50pm. At 1pm staff became aware she had not returned and carried out a search of the hospital grounds.
At 2.50pm the police were called.
At 7:45 pm the body of Mrs Brown was found at the bottom of Huntcliff in Saltburn.
The inquest heard from Pamela Brown’s daughter Rebecca Brown who said her mother's bank statements had shown she had made a payment to the bus company Arriva that afternoon. She told the inquest it was her belief her mother had got on a bus to Saltburn to take her own life.
The court heard a serious incident review carried out by the Tees Esk and Wear Valleys NHS Foundation Trust found there were 11 care or service delivery problems with Pamela Brown’s care.
The review ruled the root cause was around how Pamela’s risk had been managed and the trusts risk formulation was inadequate.
The inquest heard the trust has implemented a number of changes since Mrs Brown’s death.
The inquest continues.