A CORONER is to write to health secretary Jeremy Hunt following the death of a troubled woman who was found hanged at a Sunderland mental health facility.
A jury in the inquest into the death of Paige Bell yesterday ruled that she died as a result of “misadventure”.
The 20-year-old died eight days after being found hanging in a bedroom of the East Willows ward in Cherry Knowle Hospital in Ryhope last August.
Earlier the same day she had been rescued by police from the wrong side of the railings on Wearmouth Bridge.
However, the jury in the case added the fact that Paige was under general observation - meaning she was checked on once every hour - at the time she was found hanged, despite self-harming twice since being admitted, may have contributed to her death.
Sunderland coroner Derek Winter said that as well as writing to the health secretary, he would also be writing to Northumberland, Tyne and Wear NHS Foundation Trust (NTW), who ran the Cherry Knowle site, about observation policies and the issue of record keeping.
A contributing factor to this was contradictions within the observation policy, creating ambiguity in its application.Foreman of the jury
After the inquest, NTW bosses said they would ensure “lessons are learned” in the wake of tragedies.
Consultant psychiatrist Dr Ashok Sharma, who was part of the team caring for Paige, told the hearing that after initially being admitted on the morning of August 6, sectioned and then assessed by staff, she was kept on eyesight observation.
Those checks were downgraded to 15-minute observations, but Paige was then found by staff in her bedroom trying to cut herself with a piece of metal, and a short while later in a bathroom trying to cut herself with a hair clip.
After being further downgraded to general observation by the team, at 4pm she was found hanging in a room.
Dr Sharma said: “I felt that if we tried to prolong the restraint aspects of her care, it’s likely that would become more physically charged up.
“We were trying to normalise the situation, afford her more freedom and thereby promote a degree of autonomy and participation which would be more beneficial to her.”
Solicitor for Paige’s family, Michael Graham, had previously told the jury that Paige had tried to strangle herself on numerous occasions when under the care of Tees, Esk and Wear Valleys NHS Foundation Trust before she moved from Durham to Sunderland.
After being sent out to consider their conclusion on Wednesday morning, the jury came to a decision almost 24 hours later.
The foreman of the jury, which consisted of seven women and four men, told the hearing: “As a result of an emotionally unstable personality disorder borderline owing to self-harm and parasuicidal tendencies, Paige Louise Bell attempted an act of self-harm by applying a ligature to her neck, resulting in her death.
“A contributing factor to this was contradictions within the observation policy, creating ambiguity in its application.
Closing the hearing Mr Winter said: “I will be writing to the Secretary of State for Health and I will also be writing to the mental health trust in regard to a few matters.
“A matter for the Secretary of State to consider will be the suitability of notes being held in one place rather than following the patient from trust to trust.
“In respect of an engagement and observation policy, I will be asking the Secretary of State if there are any plans for a template for observation to be created.
“In respect of the trust themselves, I understand that a new observation and treatment policy will be implemented in April 2015.
“I have no doubt that the trust will reflect upon the evidence that was heard in the course of this inquest to ensure that the new policy will be as effective as possible.
“My report will address with the trust the issue of record-keeping.
“It has been difficult to navigate one’s way around the records that were available to have a clear understanding and chronology of events regarding Paige.
“It may be that better systems can be created electronically.”
Mr Winter added: “I have to stress that that is not a criticism. Lessons can be learned from any inquiry.”
Following the conclusion of the inquest, executive director of nursing and operations at NTW, Gary O’Hare, said: “Our thoughts are with the family and friends of Paige Bell who have our condolences.
“We are a learning organisation and take every opportunity to look at how we provide care to ensure that lessons are learned when such tragedies occur.”
Members of Paige’s family, who had been present throughout the seven-day hearing, said they did not want to comment on the inquest’s findings.
A family member provided the Echo with a picture of Paige from her youth, saying that was how they liked to remember her.