“(i) There was a considerable delay of over 60 hours before a psychiatrist attended St…”

The coroner’s concerns

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— 1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James's University Hospital to assess Mary Wanya. In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment. (ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service. (iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident liaison psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay. (iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided. (v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill. The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness. (2) Regarding the Trusts Level 3 Investigation Report prepared by Head of | Health and Safety dated 8"" February 2012. | regard this as being an inadequate and unhelpful Report, which only concentrated on the defective windows, which although a relevant issue, this Report did not address the serious issues in respect of Mary Wanya’s misdiagnosis and her inappropriate discharge from Ward 26 on 30" October 2011. The Report did not address the delays in ruling out physical illness outlined herein and the subsequent delays in obtaining psychiatric assessment. | therefore recommend that the Trust should review it’s procedures for the instigation of such Reports and should ensure that the Lead Investigator and the author of such Reports has the appropriate knowledge, experience and qualifications to address the <a | is clear to me that a person from a Health and Safety background, such as did not have the appropriate knowledge, experience and qualifications to assess medical and clinical issues, which was clearly part of the Root cause of this enquiry

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2014-0192

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0