Mum of young woman who killed herself at mental unit after care reduced says 'system let her down'

ITV Wales Reporter Hamish Auskerry spoke to Sarah Price's mother after the inquest

The mother of a young woman who killed herself at a mental unit just hours after her care provision was reduced said she feels her daughter was totally let down by the system.

Sarah Price was just 23 when she died at St Cadoc's Hospital in Newport.

An inquest heard that hospital staff in charge of Sarah's care reduced her observations "without fully taking account of Sarah's risks of self harm”.

The hearing was also told she had tried to kill herself several times in the days leading up to her death, and told staff she "did not know if she could keep herself safe" the day before she died.

Her mum Rachel said: "My daughter was screaming out for help and yet nobody was there to stop her [from taking her life]. She was meant to be in a place of safety. Mental health took her away from us through a system which let her down.”

Sarah had suffered two bleeds on the brain as a baby which affected her cognitive function and her development. She was also diagnosed with cerebral palsy and with serious mental health issues as a teenager, as well as a personality disorder and depression.

“She was a lovely, beautiful, strong, brave woman," said Rachel. "She was the class clown at school and she could drive you to distraction. But she had the biggest heart and she would do anything for anyone."

In her early teens Sarah began self harming, which escalated from the age of 17. Despite numerous medical interventions, Sarah never stopped self harming and "would find any way possible" to hurt herself.

Episodes of self harm derived from hearing "voices" urging Sarah to kill herself or her family would be harmed.

On November 13, 2015, she was admitted to St Cadoc's Hospital in Caerleon after an apparent suicide attempt at her supported living accommodation. She was then detained under the Mental Health Act.

She had been admitted to the psychiatric hospital on numerous occasions before.

However, this time hospital staff described her demeanour as "different to her previous admissions”, that she "did not engage in the way she had done previously” and was “very sad, particularly sad".

While at the hospital, Sarah made multiple attempts to leave, as well as attempting to take her own life – both inside the hospital and when she had absconded.

She also repeatedly told staff and her family "she wanted to die", and the day before her death said "she was not sure if she could keep herself safe”.

Three months after she arrived, on February 2, 2016, she was found collapsed in her bathroom. A post mortem later ruled Sarah had died as a result of asphyxiation.

A four-day inquest held at Newport Coroner's Court was told that on the morning of Sarah's death staff observations were reduced from constant checks within the eyeline of staff to once every 15 minutes.

“I had spoken to Sarah that morning and she had told me they were taking her off her observations and that she was scared she was going to take her own life," recalled Rachel.

"She told me she was worried. I was promised that morning that my daughter would be safe, but she wasn’t.

“Risk assessments are vitally important. To identify the risk [of suicide] and not remove the risk is totally wrong. Yes she may have found another way to kill herself, but you should try as much as possible to remove that risk.”

Rachel had just finished a shift as a support worker when she received the news about her daughter.

“I was totally oblivious, I couldn’t cry, I felt numb,” she said. “I was the only person on that day asked to give a statement.”

On the morning of her death the inquest heard how Sarah "still felt stressed by her thoughts and that the medication was not working".

However, a coroner said that evidence to show the incidents in which Miss Price had self harmed, as well as possible risks, had been recorded in medical notes. And the hearing was told that all relevant staff would have seen these notes before the decision to downgrade the observations were made.

After their deliberations, a jury at the inquest found that Sarah had taken her own life and that hospital staff decided to downgrade her observations on the morning of her death "without fully taking account of Sarah's risks of self harm". They concluded that "Sarah's death was contributed by neglect".

Her family welcomed the conclusion and said it had brought them some semblance of closure after "throwing everything at the case” over the past five years.

Rachel added: "We can’t bring Sarah back but we can make a difference for others now.

"I’ve seen how this has impacted our family. I worry every day. Statistics show when one family member takes their life other relatives can do the same. I have been worried my boys would do that too.

“I was so concerned I contacted Papyrus [suicide prevention charity] for advice on how to help my children.

“I have been strong because I know things need to change. Life is extremely difficult. People see my smile, they don’t see my anxiety.

"My young lads want to go out and enjoy themselves and I’m worried sick about them. That feeling never leaves you.

“My grandchildren are a breath of fresh air and I live for them and live for my children. Sarah is still with me too - twenty-four-seven.

“The last few days have been like hell on earth. I’ve listened to things said about my daughter, some of it has been very upsetting.

“I felt it was implied that my daughter was an attention seeker. She was very ill. If you had cancer you wouldn’t be thought of as an attention seeker. My daughter needed help, that might have been five minutes of someone’s time."

A spokeswoman for Aneurin Bevan University Health Board said: "Our thoughts are with Sarah’s family at this difficult time.

"The Health Board conducted a thorough Serious Incident investigation into the care Sarah received in St Cadoc’s Hospital in 2016 and the findings have been shared fully and openly.

"The Health Board took corrective actions at the time of the incident and following the investigation and we acknowledge the outcome of the inquest."

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