“By their conclusion expressed above, the jury were satisfied that on the evening of…”

The coroner’s concerns

– (1) By their conclusion expressed above, the jury were satisfied that on the evening of 21.3.20, when Emily tied the ligature which resulted in her death, staff on Holt Ward, Newtown Hospital, Worcester failed to carry out an adequate assessment of Emily's capacity to make a decision about taking Lorazepam to reduce her extreme anxiety and distress, and had they done so, they would have found that she lacked capacity in that regard, and would have administered an intramuscular injection of Lorazepam "in best interests"; (2) In the note which she made about these events on Care Notes, dated 22.3.20, staf f nurse MM recorded as follows: 2 "I offered her Oral Lorazepam, but she refused, however [ Deputy Ward Manager ] stated unable to give IM Lorazepam due to her being an informal patient and had already had IM administered under best interest on 19.3.20. On the balance of probability, Emily had capacity to understand that she was informal and that we could not administer medication under MAPA therefore team decided that IM should wait for further guidance from medic following his assessment for section 5.2." (3) In her evidence, staff nurse denied that this was the test which was applied when deciding whether or not to give IM Lorazepam to Emily, but was unable to explain why she had recorded otherwise in the Care Notes, and why she had not corrected herself when making her statement for the inquest only 2 weeks after the incident, save to say that she had been distressed by what had happened. (4) In her evidence, Deputy Ward Manager said that the reason she had not administered IM Lorazepam to Emily was because she had assessed her capacity to make a decision about such medication during an incident outside the nurses' office about an hour before the fatal ligature, and had concluded that she did have capacity to ref use it. She said that she had not formally assessed Emily's capacity thereafter because she did not think Emily required Lorazepam. She said that staff nurse had recorded the test she applied wrongly in the Care Notes, because she may not have understood what she ( ) was saying. (5) By their conclusion, the jury found that if an adequate assessment of Emily's capacity had taken place, she would have been given IM Lorazepam "in best interests", that this would have quickly relieved her anxiety and distress, and that her death would probably have been prevented. (6) Although staff on Holt Ward were undoubtedly having to deal with a very difficult situation in this case, I am concerned that if a such a decision has to be made in similar circumstances in the future, staff may not apply the correct test under the Mental Capacity Act 2005, and there is therefore a risk of future deaths occurring.

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, 2022-0092

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