Multiple opportunities missed to prevent suicide death at NHS mental health unit, inquest hears

A 40-year-old mother of four took her own life at an NHS mental health unit after multiple opportunities were missed to keep her safe, an inquest has found, prompting her family to call for a public inquiry.

Azra Parveen Hussain was allegedly the seventh in-patient in seven years to die by the same means while in the care of Birmingham and Solihull Mental HealthNHS Foundation Trust (BSMHT).

Despite this, an inquest at Birmingham and Solihull Coroner’s Court last week heard that the Trust had not installed door pressure sensor alarms, which could have potentially alerted staff to the fatal danger these patients faced.

While BSMHT is now taking action to install pressure sensors at Mary Seacole House, where Hussain died on 6 May, Coroner Emma Brown noted a lack of national regulation or guidance on the risks presented by internal doors in patients’ bedrooms and is issuing a Prevention of Future Deaths report calling for this to be remedied across the country.

Laywers for Hussain’s family alleged that both the inquest and a recent report by England’s independent healthcare regulator, the Care Quality Commission (CQC), “expose several deeply troubling failings that led to her tragic, avoidable death”.

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The inquest, which concluded on Monday, heard of a series of failings at Mary Seacole House in Hussain’s case, without some of which the jury concluded she may still be alive.

What happened during Hussain’s time in hospital?

After being sectioned in December 2019 as a result of mania caused by bipolar affective disorder, Hussain became severely depressed.

She was due to receive electroconvulsive therapy (ECT) in March to treat her depression, but an administrative error meant this did not take place – which the jury concluded could have prevented her death.

On 4 May 2020, Hussain told her family that she had attempted to take her own life, using the same method by which she died two days later. They alerted the nurse in charge who found no evidence of the attempt, which Hussain denied to them, and she was deemed not to be an immediate risk. While BSMHT later accepted this development was “significant”, the staff on duty did not document the family’s concerns or raise an incident report.

Furthermore, Hussain’s risk assessment was not updated, and other hospital staff, including her doctors, were not informed – allegedly with four missed opportunities in total to pass the information on. There was no increase in the level of observations for Hussain, which were reportedly every 15 minutes, and other objects that she could potentially use as ligatures were not removed from her room, the inquest heard.

And just hours before Hussain’s death, her family was excluded from a multidisciplinary meeting, during which they could have raised concerns about her safety, their lawyers said.

What action is being taken?

In her report, the coroner called on BSMHT to ensure that from now on families can attend multidisciplinary team meetings, using a remote platform or by telephone – in addition to a call for action to remedy the risk posed by the lack of sensor alarms in in mental health units across the country.

Meanwhile, the CQC had previously called on BSMHT – which said it accepts the inquest’s findings in full – to address all ligature risks by June.

In an unannounced inspection of the Trust in November, including of the ward where Hussain died, the CQC said its investigators “found several concerns that needed addressing” and had “imposed urgent conditions on the Trust’s registration as a result of our concerns about ligature risks, care planning and risk assessments”.

“We took this urgent action to ensure that people using the services are not exposed to any risk of harm,” said the CQC’s head of mental health hospital inspections, Jenny Wilkes, said in January.

“The Trust responded quickly to safety concerns in most cases but in some instances, such as the ongoing ligature risk presented by ensuite bathroom doors on the acute wards, no timeframe was given for when this work would be complete.

“We have reported our findings to the Trust leadership, which knows what it must do to bring about further improvements and ensure it maintains any already made. We will return to check on the trust’s progress.”

Acting on behalf of Hussain’s family, associate legal director of Novum Law, Mary Smith, said: “Azra’s inquest and the recent CQC Report expose several deeply troubling failings that led to her tragic, avoidable death.  Most shockingly of all, the Trust appears to have wholly failed to learn from six earlier deaths in similar circumstances, by ensuring installing a simple pressure alarm system.

“Death by hanging is one of the most common methods of suicide in mental health patients. Patients detained under the Mental Health Act have a right to expect to be kept safe by those responsible for their care, both through adequate risk assessment and observation and in ensuring that the environment they are cared for in is a safe one.

Ms Smith welcomed the jury’s verdict and the coroner’s decision to issue a Prevention of Future Death report, adding: “It is vital that when things go wrong, lessons are learnt, and the risk of any future harm is prevented.  The hope now is that those with the power to make the necessary changes do so.”

Hussain’s children described their “beautiful and pure-hearted” mother as “the foundation of our family and the reason why our house felt like home”.

“With the assistance of our legal team, the coroner and the jury, we have now taken the first step towards justice for mum and to make things safer for others,” they said in a statement. “This means everything to us.  Although there will always be a void in our hearts, we now feel a little less empty.”

BSMHT chief executive Roisin Fallon-Williams said: “Our thoughts and condolences are with Azra Hussain’s family at this very sad and distressing time for them.

“We fully accept the findings of HM Coroner and whenever such a tragic incident occurs we undertake a thorough investigation to identify any actions to prevent a similar incident in future.

“We have been addressing risks based on learning from incidents and we have already made a commitment to fit alarm systems on ensuite bathroom doors, for which we have begun a roll out plan to achieve across all acute wards and psychiatric intensive care units.

“We are implementing a range of other improvements alongside this to mitigate risk and improve the safety and quality of care.  These include daily safety huddles and improvements in care plans to reflect our personalised approach and robust risk assessment processes.

“Additional therapeutic activities on wards will aid service users’ recovery, and we are recruiting more health care assistants as well as undertaking a comprehensive review of our approach to therapeutic observation.

“We are committed to making these changes and to continually seeking to identify where further improvements can be made to ensure safe and high quality care to all our service users. This includes ensuring appropriate involvement of families and carers.”

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