“The enhanced carer had not been told the reason that she was providing one to one care…”

The coroner’s concerns

– (1) The enhanced carer had not been told the reason that she was providing one to one care for Sarah, was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that Sarah was a risk of deliberate self harm including by overdosing on prescribed medications. She was not aware that Sarah had been discharged with seven days of medication or that her medication was being held on her behalf by another in the community. Although it was unusual for her to accompany a person with capacity to their address it was not unusual for her to accompany those without capacity. As a consequence the support worker who was on duty at the time that Sarah returned to her accommodation was not aware from an independent source that Sarah had been discharged with seven days of medication, Sarah lied to the support worker when she was asked whether she had been given any medication disclosing only the fact that she had been given ferrous sulphate which she handed over when her bag contained seven days of the medication which she subsequently ingested with fatal results. Even recognising medical confidentiality, those with a caring role who have not been provided with relevant information cannot meet the needs of the patient if they do not know what the risks are or know when it is appropriate to bring information to another professional charged with the care of the patient be it a nurse, doctor or support worker (2) The note left by the psychiatrist on the medical records did not contain any recommendations as to medication. The psychiatrist was aware that Sarah’s medication was being held by her support workers as a result of the risk of mismanagement by overdosing. He was also aware that it was policy for the hospital to dispense 14 days of medication on discharge. He did not consider asking the discharging doctor to not provide Sarah with any medication on the basis that there was already a prescription in the community and although he considered that it was appropriate for the quantity of discharge medication to be reduced to seven days to reduce the risk of overdose, he did not communicate this to the medical team within the note. (3) The note left by the psychiatrist on the medical records contained the abbreviation DSH. it was clear from the evidence given at the inquest that this was not universally understood by the medical team to refer to deliberate self harm. Although the Trust has taken some action following the evidence being given at the inquest in that the psychiatrist after giving evidence sent an e-mail to his team detailing his reflections iteam to request that consideration be given to a number of matters in dealing with patients at the hospital. Having considered the e-mail I did not regard this as meeting the extent of my concerns

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, 2024-0123

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