Woman who died in mental health unit had told staff she 'didn't know if she could keep herself safe'

A woman told hospital staff she "did not know if she could keep herself safe" the day before her care provision was reduced, an inquest has heard.

Sarah Louise Price, from Newport, died on February 2, 2016, in Caerleon’s St Cadoc’s Hospital after being detained under Section 3 of the Mental Health Act.

The second day of an inquest held at Newport Coroner's Court on Tuesday, October 5, over five years after her death, heard how Miss Price had taken her own life on February 2, 2016, hours after observations were reduced.

On the morning of February 2, the 23-year-old's observations were reduced from level three, which meant she was under constant observations within the eyeline of hospital staff, to level two, which warranted checks every 15 minutes.

The inquest heard how she had tried to kill herself several times in the days leading up to her death. The inquest also heard how Miss Price absconded from the hospital between nine and eleven times in the months leading up to February 2, and regularly told staff about her wishes to harm herself.

On the first day of the inquest her mother, Rachel Price, provided a witness statement to the coroner Caroline Saunders, where she described how her daughter had first started self harming in her early teens, which escalated from the age of 17. She said despite numerous medical interventions "Sarah never stopped self harming" and "she would find any way possible".

Miss Price said that the episodes of self harm derived from hearing "voices" which, she said, would tell Miss Price to kill herself or something would happen to her family members.

Miss Price suffered two bleeds on the brain as a baby which affected her cognitive function and, as a result, her development. She was also diagnosed with cerebral palsy and diagnosed with serious mental health issues as a teenager.

Miss Price was also diagnosed with a personality disorder and depression.

In giving a witness statement as evidence in the second day of the inquest, Miss Price's care coordinator Lisa Williams told the court that she thought it "generally better" for Miss Price to be observed under level two unless there was a "specific risk that day".

She explained that under level two the hospital had agreed with Miss Price's family that she would be able to leave the ward, which Ms Williams thought was "important" for Miss Price.

She also explained to the court how the levels of observations could be altered daily depending on whether a new risk had been reported i.e if an incident had occurred on the ward.

Representing the family of Miss Price, Ms Kirsten Heaven referenced medical notes - including a care plan and risk assessment - for Sarah relating to her stay in the hospital.

The inquest heard how Miss Price had attempted to take her life on January 24, 26 and 29 however the last update to Sarah's risk report was completed on January 27, six days before her death.

Ms Heaven questioned Ms Williams as to whose responsibility it was to update these reports, and said it was "incomplete" at the time of Miss Price's death.

Ms Williams told the court how she was part of a team of staff including the the consultant psychiatrist at the hospital and the ward manager who decided the level of observations Miss Price would receive in a 'Ward Round' meeting held on February 1.

In this meeting it was discussed whether Miss Price could be downgraded from level three observations to level two and Miss Price was asked “do you think you can work with us?” to which Miss Price said she would "try." It was at this meeting where Ms Price also said she "doesn't know if she can keep herself safe".

The inquest was told that hospital staff hoped the move to level two would "motivate" Miss Price as she would be permitted to spend leave with family.

Mr Tom Leeper, acting as a representative for the Aneurin Bevan University Health Board, asked Ms Williams what were the potential long term benefits to moving Miss Price to level two observations.

Ms Williams said that there was a risk that "you become reliant on 1-1" observations, and that patients needed to "develop coping strategies." Mr Leeper summaries this by stating that hospital staff sought a "balance" between the observation levels.

He said that if the observations were not constant, there was an increased chance the patient could self harm, however, if constant there is the risk the patient would become "reliant" and "not get better". Ms Williams agreed with this summary.

Before her admission to St Cadoc's from a supported living accommodation in November 2015, Miss Price had been an inpatient at the hospital several times since she was 18.

However, the inquest heard several statements from hospital workers who said Miss Price was "different" during her last admission.

Lewis James, who was a healthcare support worker, said that Miss Price was "different to how I had seen her previously."

He also told the inquest that there had "always been an intention to self harm but this time she seemed more motivated to carry this out."

On the first day of the inquest, the court was told how Miss Price had undergone 12 sessions of electroconvulsive therapy (ECT) in an attempt to combat her depression. The inquest heard that while this appeared to improve her mood and biological reactions to the depression, it also left her more "motivated" in acting on what the voices were telling her to do.

However, many people gave witness statements that Miss Price's mood - although very low - was "fluctuating" after receiving the therapy.

Dr Samaneh Moghaddacy, a Psychiatrist working under the direction of Dr Jamil - who gave evidence on the first day of the inquest - said that Miss Price was "fluctuating in how she presented" to hospital staff.

She said that in the 10 days before her death, Miss Price's urges to harm herself were "more intense" and referenced these for periods spent at observation level three.

On January 27, Miss Price was de-escalated from alert level three to alert level two. In questioning this decision Ms Heaven referenced medical notes and asked why this decision was made when Miss Price "still has constant thoughts of getting out and killing herself."

Dr Moghaddacy said the downgrading had been set out in a meeting on the previous day, and that a balancing act needed to occur.

The hearing later heard how Miss Price was once again upped to level three observations after two incidents on the ward in which she had "pushed boundaries," on January 29. In medical notes provided from hospital staff she pushed past a member of staff and attempted to lock herself in a toilet. When staff entered she was in the process of removing a bag from the bin. The second occasion referenced was that she locked herself in her bedroom.

In continuing the questions to Dr Moghaddacy, Ms Heaven asked why on Feb 2 was the decision made to again lower Miss Price to level two observations when her "thoughts are the same" and Miss Price "doesn't know if she can keep herself safe."

Dr Moghaddacy said that despite this, on the morning of her death Miss Price appeared "bright" and that "there was a light in her eye" and stated that at the time she did not think it was a wrong decision to reduce the observations on the 2nd when considering long termsolutions.

In giving evidence, Mr James Robinson, who was the deputy ward manager at the time of Miss Price's death, said that on the morning of Feb 2 she was "bright," "engaged" and it appeared to him that she had "turned a corner in her ability to engage". However, he did acknowledge that despite this there was a "chronic suicidal risk."

In questioning Mr Robinson, Mr Leeper asked him to explain to the court whether he believed that each of Miss Price's previous attempts to take her own life had been genuine attempts, and whether it was possible to differentiate these from instances of self harm with no intent.

Mr Robinson said that in his opinion the incident on January 26 "didn't feel it was a genuine attempt at that time because there was an attempt to seek help by shouting out."

He also said that professionals were "usually clearly able to distinguish between suicide and self harm with no intention to die."

Ms Maureen Froude, a healthcare support worker who had been in contact with Miss Price since the age of 18 gave evidence at the inquest and said that "Sarah was very sad on this admission".

She also said: "I don't think that any medication made any difference" in the long term but that the ECT had made Miss Price "brighter".

The inquest, which is being heard by a jury, continues.