Patient hanged herself after psychiatric unit rejected her
A MOTHER suffering serious anxiety hanged herself days after being turned away from the psychiatric unit where she was desperate to be admitted.
An inquest in Port Talbot yesterday was also told the junior doctor in charge of the unit had received no training in psychiatric medicine.
Sewing machinist Avril Thorne, 49, of Sandfields, Port Talbot, had a history of mental illness and had previously slashed her wrists.
But when she reached crisis point and went with her steelworker husband Paul, 51, to ask to be admitted to the Neath Port Talbot Hospital psychiatric unit in Baglan Moors, she was classed only as “low-to-some risk” and sent home.
The unit’s low-risk assessment was made despite referral notes from Mrs Thorne’s out-of-hours GP, who said: “She says she will do something unless admitted.”
Junior doctor Mahibur Rahman and mental health nurse Lindsey Martin had also noted that she “can’t cope” and “now feels at the end of her tether and feels life is not worth living” in their own assessment of Mrs Thorne.
Neath Port Talbot Coroner Philip Rogers was told that even though she was not admitted to the hospital on Saturday, March 25, 2006, a “safety net” was arranged for her.
This included arrangements for an out-of-hours mental health team to contact her at home and for an emergency appointment to be made the following Monday.
But the arrangements were not put in place.
Mr Rogers said: “The evidence is quite clear, notwithstanding the support Dr Rahman intended to be put in place, not all the support was made available.”
Five days later Mr Thorne, who had not been contacted by the former Abertawe Bro Morgannwg NHS Trust which was running the unit, left his wife briefly to attend to his boat at Port Talbot docks.
When he returned to his home at Vivian Park Drive, Sandfields, he found his wife hanged from banisters. She could not be revived.
Mr Rogers yesterday recorded a narrative verdict, which included the NHS failing to follow through with its plan of referrals and treatment.
As a result the coroner made a recommendation under the Coroners’ Rules requiring the NHS to change the forms used for referrals to ensure they are actioned appropriately.
The narrative verdict also recorded that her husband Paul Thorne did not receive the support to which he was entitled.
Mr Rogers apologised to Mr Thorne for the length of time the inquest had taken to be held.
During the inquest Dr Rahman, now a GP, frankly admitted that when Mrs Thorne came to the psychiatric unit he was doing his GP training.
Despite being the junior doctor in charge, he had received no specialist psychiatric medicine training beforehand and had been in post for only a few weeks.
Nurse Martin added she had only been in post at the time for a few months.
They told the inquest they decided not to admit Mrs Thorne because, in an interview lasting more than an hour, she told them she had made no plans to kill herself and was concerned about her daughter and granddaughter.
They added they felt her problems were “social” and admitting her would only have given her temporary respite.
James Bell, clinical negligence specialist at Russell Jones & Walker solicitors, representing Mr Thorne, said afterwards: “This inquest highlighted a catalogue of administrative, system and clinical errors by the NHS.
“The NHS has already admitted liability in the civil claim on behalf of Mr Thorne, but there is a need for serious consideration of what happened to Avril Thorne to ensure the same thing does not happen to other vulnerable patients.”
Outside the Coroner’s Court Mr Thorne said: “I do not blame any one person for my wife’s death – I blame the system.”