AN IRISHMAN has called for lessons to be learnt following an inquest into his wife’s death at a Coventry mental health hospital.
Teresa Doherty, 43, was found unconscious in the bathroom of her room at the Caludon Centre on March 1, 2016 about an hour after she had last been seen.
The mother-of-five died from a cardiac arrest caused by a lack of oxygen.
Assistant coroner Bina Patel, who sat with an 11-person jury, recorded a narrative verdict, concluding Teresa “died as a result of her own deliberate act” but it was not known “whether she intended that act to cause her death”.
The inquest at Coventry Crown Court heard how, four days before her death, staff relaxed Teresa’s 15-minute observations to every hour.
Despite her later telling doctors the day before she died that she ‘wouldn’t think twice about ending her life’, her observation period was not amended.
Speaking after the inquest, Theresa’s husband John Doherty said: “I repeatedly told the staff to keep an eye on Teresa because I was very worried for her welfare.
“I knew my wife and what she had been through better than the staff but it felt like my concerns were just dismissed.”
Investigation
Following Teresa’s death, her family instructed medical negligence lawyers at Irwin Mitchell to investigate her care under Coventry and Warwickshire Partnership NHS Trust, which runs the Caludon Centre.
An NHS investigation found no evidence to support the decision to change Teresa’s observation period.
It also found that there was inadequate ongoing assessment and monitoring of Teresa’s mental health state during her stay, and no documented evidence of one-to-one support or planned therapeutic interventions.
Move from Ireland
Teresa and John, 41, who had been married since 2002, moved from Ireland to Nuneaton in 2014.
In October 2015 Teresa gave birth to the couple’s youngest child.
The inquest heard Teresa, who had a 15-year history of anxiety and depression, was accepted as a voluntary admission to the Caludon Centre on February 20, where she was prescribed anti-depressants and placed on 15-minute observations.
On February 26, her observation period was downgraded following a review between a doctor and nursing staff.
However three days later, Teresa reported feeling ‘very bad’, that she ‘didn’t want to live anymore’ and ‘wouldn’t think twice about ending her life’, a Root Cause Analysis Investigation Report found.
On 1 March, 2016, Teresa was seen in a communal area at about 4pm.
At 5pm a staff member went to check on her in her room and found Teresa unconscious.
Staff tried to resuscitate her but she was pronounced dead.
The Root Cause Analysis Report found that a lack of information about the management of Teresa’s care and a lack of clinical explanation about why she was kept on hourly observations following her assessment on February 29 contributed to her death.
The report confirmed the Trust’s ‘contraband’ policy had been adhered to.
'Heartbreak'
Speaking after the hearing John said: “Our family’s only hope now is that the heartbreak we have suffered highlights the need for those with mental health issues to receive swift and appropriate treatment.
“We hope that the Trust continues to learn from the issues which have been highlighted at the Inquest to ensure other families are spared the pain we have to endure on a daily basis.”
Laura Daly, Senior Associate Solicitor at Irwin Mitchell, called on the NHS Trust “to ensure it recognises the concerns that the NHS’s independent investigators found, hopefully meaning other families don’t have to suffer the heartache that John and the rest of Teresa’s family have endured following her death.”
In a statement, Simon Gilby, Chief Executive at Coventry and Warwickshire Partnership NHS Trust, said: “We would firstly like to express our sincere condolences again to the family of Teresa Doherty.
“We have fully engaged with the family and have conducted an open and transparent investigation, the results of which were shared with the Coroner and scrutinised at the inquest.
“Events like these are rare but, when they do happen, we do all we can to ensure that lessons are learned.
“We remain committed to ensuring the safety of all patients in our care at all times and providing high quality care and will take the learnings and coroner’s remarks into account when reviewing our services to ensure they are continually improved.”
