Pamela Brown Inquest: Daughter urges trust to learn from events which led to mother's suicide
Report by Katie Cole
The daughter of a Redcar woman who took her own life after escaping from a mental health hospital is calling for lessons to be learnt.
An inquest heard 57-year-old Pamela Brown took her own life whilst detained under the mental health act at Roseberry Park Hospital in Middlesbrough in September 2019.
She absconded after being granted ten minutes of unaccompanied leave in the hospital grounds to go for a walk.
Her body was later found beneath cliffs in Saltburn.
The inquest at Teesside Coroners Court heard the Tees Esk and Wear Valleys NHS Foundation Trust underestimated the risk Pamela Brown posed to herself.
A jury found 'the overall formulation of risk' of Mrs Brown was inadequate and that contributed to her taking her own life.
The trust's own internal investigation found 11 problems in the care and delivery of services to Mrs Brown, who had been detained under the mental health act two weeks prior to her death.
Her daughter, Rebecca Brown, is now calling for the trust to learn from its mistakes and implement changes to prevent the incident from ever being repeated.
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 early 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 be admitted to 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 - 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.
Ms Ross said on 20 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.
Following Mrs Brown's death, the hospital trust published a serious incident report, which identified 11 "failings" in Pamela's care.
These included missed opportunities to share information, a lack of acknowledgment about her family's concerns and that "risk assessments had been inadequate".
The trust say they have implemented changes and "will continue to make improvements" to their services.
Our thoughts and deepest sympathies are with Pamela’s family and friends and we remain desperately sorry for their loss," said Ann Marshall, deputy director of nursing at the trust.
"We note and accept the inquest findings, which reflect the outcome of a review the Trust carried out following Pamela’s death in 2019.
"This review led directly to significant improvements including in clinical risk management processes, training, and engagement with carers and families.
Rebecca Brown remembers her mother as a "sociable and bubbly" person who had time for everyone.