PATIENT observation procedures were already under review when a troubled young woman was found hanged at a Wearside hospital, an inquest heard.
Paige Bell’s death at Cherry Knowle psychiatric unit in Sunderland comes after four previous deaths in similar circumstances in the same NHS trust.
Paige, 20, died from oxygen starvation to the brain eight days after she was found hanging in her room on August 6, the inquest heard.
She had been taken to the hospital by police after she was pulled from the wrong side of the railings of the Wearmouth Bridge in the early hours that day.
Concerns had been raised over observations levels at Cherry Knowle as Paige had self-harmed twice the day she died, coinciding with check-ups from staff.
Serious incident investigator Peter Traynor previously said in his evidence, that when Paige was found hanged she could have been “hoping, even expecting” to be discovered in time.
On the fifth day of the inquest at Sunderland Coroner’s Court, the jury heard evidence from Anthony Deery, group nurse director for urgent care services, at Northumberland Tyne and Wear NHS Foundation Trust (NTW).
Mr Deery said the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness had provided recommendations to the trust in October 2013 – 10 months before Paige died.
He said: “The confidential inquiry looked into some serious and untoward incidents and recommended we should perhaps move to irregular timing. For people with emotionally-unstable personality disorder, you don’t say that is going to take place on the hour. It needs to be unpredictable.
“In their analysis they felt patients often timed self-harm behaviour to coincide with the actual time the observation was going to take place. We had evidence of that because of a previous death that had occurred at the trust.”
Mr Deery said one of the deaths was of a woman suffering from EUPD, who had a history of putting ligatures around her neck. These incidents had happened on the hour when staff were coming to observe her and “on a number of occasions” she had been saved.
“Sadly on this day in question at one of these observation points, staff were attending to another incident happening on the ward and didn’t get to this patient on the hour.”
A new observation policy – now called the engagement and observation policy – was trialed at St George’s hospital in Morpeth and is due to be rolled out south of the Tyne at the end of this month.
Under the new policy those under hourly observation, like Paige was when she was found, will be observed during various points of the day, coinciding with meal times activities and medication.
Mr Deery said all four deaths reviewed were as a result of either hanging or strangulation with a ligature, they were all women aged between 30 and 40 and all suffered emotionally unstable personality disorder.
The inquest will resume on Tuesday.
Paige described as a ‘lovely lassie’
THE manager of a Sunderland homeless hostel where Paige Bell was staying called her “a lovely lassie” who had appeared in good spirits until she received a mystery phone call shortly before she was rescued from the Wearmouth Bridge.
Giving evidence at the inquest into her death, service manager Christine Ritchie said Paige had arrived at Swan Lodge in High Street East on June 26 last year.
Ms Ritchie described how there were two sides to Paige, when she was lucid she was “lovely” and had a passion for art, but when her mood changed she could be violent and had faced eviction for trashing her room.
“Paige was quite a troubled young lassie who had multiple, multiple issues with drugs and alcohol,” Ms Ritchie said. “But when Paige had a lucid moment she was lovely lassie and one of the most beautiful artists we have had at Swan Lodge.”
On the night before she climbed on top of the bridge Paige appeared in good spirits, until something changed her mood, Ms Ritchie said.