Woman killed herself after south London hospital neglect, coroner concludes | Hospitals

A woman killed herself after a south London psychiatric unit failed to adequately search her belongings, a coroner has concluded.

Michelle Sparman, a personal trainer and call dispatcher for the Metropolitan Police in Battersea, southwest London, died on August 28, 2021 at Kingston Hospital, four days after attempting suicide.

Deputy coroner Bernard Richmond KC concluded that Sparman, 48, died of a hypoxic brain injury, determining that she died by “suicide while the balance of her mind was disturbed, due to neglect”.

He determined four probable causes of death: his struggles with anxiety and depression, including impulsivity; a “difficult relationship” with her ex-partner, including “intemperate and excessive text messages” from her, which called into question her mental health and her ability to be a mother; her “justifiable feelings of abuse” due to her behavior and inadequate searches upon leaving and entering Rose Ward, a 20-bed, locked, women’s mental health unit at Queen Mary Hospital in Roehampton.

He cited her perimenopausal symptoms and financial and work problems as possible causes.

He said Sparman presented herself as a voluntary inpatient at Rose Ward, with clear “red flags” that she was at risk of harming herself.

He added: “The duty to protect a person in a mental health service from injury with objects seems to me to be a fundamental obligation of the service.

“The failure to do adequate research is so fundamental that it easily passes the Jamieson test. [a standard of proof for a finding of neglect in an inquest] …She did precisely the thing she should have guarded against.

Richmond will also produce a report on preventing future deaths examining the need for mental health services to introduce a centralized register of all dangerous objects on the ward, which it plans to submit to NHS England given its potential national implications.

Richmond noted the impact of Sparman’s “difficult relationship” with ex-partner Roger Stephens, and although he felt there was “undoubtedly a lot of love between them”, the relationship acquired a “certain toxicity”.

He added that Stephens’ messages amounted to harassment and left Sparman feeling “trapped”, but he did not believe it was done “deliberately”.

In May, during five days of evidence, Inner West London Coroner’s Court heard how Sparman’s mental health deteriorated following the breakdown of his 28-year relationship in January 2020.

In texts sent to her siblings, Sparman said she might “end up killing myself” because of Stephens’ subsequent behavior.

Stephens told Richmond that “in hindsight I shouldn’t have sent so many text messages”, and acknowledged that they were “very angry” and had “put stress on him”.

On August 21, 2021, Sparman was taken to the hospital after Stephens discovered she had overdosed and self-harmed. Sparman was classified as a “red zone,” meaning she was supposed to be searched for dangerous items.

Ward Manager Meredith Kuleshnyk, who found Sparman, said lessons were learned, including increased training of staff on searches and the provision of a search room.

Although he acknowledged the staffing pressures the department was experiencing, Richmond determined the lack of record keeping was “a deeply concerning situation.” Despite evidence suggesting Rose Ward’s practices had changed, Richmond said he was not convinced a “robust recording system” was now in place.

Jennifer MacLeod, the lawyer representing the family, cited statistics showing that at Rose Ward in 2020 there were 70 cases of self-harm – indicating staff intervened before they could attempt suicide.

Kuleshnyk also told the inquest that she planned to discuss domestic violence with Sparman after observing his interaction with Stephens.

In a self-referral to Talk Wandsworth, a talking therapy service, Sparman said Stephens’ behavior “impacted my sleeping, my eating, my confidence, my emotional and mental wellbeing”.

Shaun Case, Sparman’s half-brother, said she spoke of “anxiety, tightness in her chest when her [Stephens’] his name came up on her phone,” and that she feared he would arrive at her apartment.

MacLeod said: “The family’s position is that they perceived this as abuse, and every medical professional we’ve heard from perceived this as abuse. »