Nurse tells inquest mental health patient seemed “relaxed” shortly before escaping from hospital
A nurse has told the inquest into the death of a Redcar woman she seemed relaxed shortly before escaping from a mental health hospital.
57-year-old Pamela Brown died on September 20th 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 walk in the grounds of the hospital.
Mrs Brown’s body was found later that evening at the bottom of Huntcliff in Saltburn.
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.
Staff nurse Sarah Ross from Tees Esk and Wear Valleys NHS Foundation Trust assessed Pamela Brown before she was granted leave on the 20th September.
She told the court unsupervised leave in the hospital grounds had previously been agreed as part of Mrs Brown’s care plan.
She said on the 20th September Mrs Brown "presented more relaxed" after being given anxiety medication earlier in the day and she considered going on a 10-minute unsupervised walk was a reasonable request.
Asked by the coroner "how often do patients go awol,” Mrs Ross said it was not a common occurrence. Given how much leave is granted, it could be weekly, she explained.
She added while most patients return there are times when things go wrong. She told the inquest, "in my whole career this happened to me once.”
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.
She had been under the care of Tees Esk and Wear Valleys NHS Foundation Trust since the 5th August after taking an overdose of sleeping tablets.
She was first under the care of a community team before being admitted to Roseberry Park Hospital in Middlesbrough as an informal patient on 15 August.
After a number of incidents including drinking eye cleaning fluid on the ward, ingesting disinfectant whilst on overnight leave and going missing from the Mrs Brown was detained under the mental health act on the 6 September.
The inquest heard the trust's own internal investigation had found 11 problems in the care and delivery of services to Pamela Brown with the root cause being the risk formulation of Mrs Brown was inadequate.
A serious incident report read to the court found relevant historical information had not been taken into account when assessing Mrs Brown’s risk, there had been a lack of acknowledgement about her families concerns and an underestimation of the risk Pamela Brown posed to herself.
The inquest heard the trust has implemented a number of changes since Mrs Brown’s death including steps to improve the quality of risk assessments and increasing contact with patient's families.
The jury returned a narrative verdict and found 'the overall formulation' of Mrs Brown's risk was inadequate and this contributed to her taking her own life.