A WOMAN who died in St Cadoc’s Hospital just days after attempting to take her own life multiple times had her observation levels downgraded on the day of her death.
Sarah Price died aged 23 on February 2, 2016.
Dr Samaneh Moghaddacy, a psychiatrist who was a junior doctor at St Cadoc’s at the time, was asked about why the decision was made to downgrade Miss Price’s observation level from constant to 15-minute check-ins on the day of her death.
READ MORE: Woman attempted to take her own life twice in hospital just days before she died.
“On that day she looked brighter,” said Dr Moghaddacy. “There was a light in her eye. She never had that before.”
Kirsten Heaven, representing the Price family, read out Miss Price’s medical notes for February 2, 2016.
They said: “Sarah says the thoughts are still the same.
“She’s not sure if she can keep herself safe with lower observation but says she will give it a go.”
“She says that she is telling the team that she has thoughts to kill herself, but the observations were still downgraded?” Ms Heaven asked.
“Yes,” Dr Moghaddacy said.
“There was a focus on trying to support Sarah over the weekend to go on leave [to visit her family],” said James Robinson, who was the deputy ward manager.
“It was really positive. She had washed; she had contacted her mum about bringing her items of clothing; she was bright and engaged.”
Mr Robinson said the team “acknowledged there were risks” with Miss Price.
“It’s important to consider it within their diagnosis,” he said. “What we are trying to assess is the intent to carry out their thoughts. The challenge is that these thoughts can be constant or very very active.”
Tom Leeper, representing Aneurin Bevan University Health Board, asked Lisa Williams – Miss Price’s care co-ordinator – what the downsides of constant one-to-one observation.
“You become reliant on the one-to-one,” she said. “You need that person that you are with.
“You need to develop coping strategies of your own rather than relying on someone else all the time.”
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Ms Williams was asked about Miss Price’s risk assessment and management plan, which had been updated on January 11 and January 27.
In the month before her death, Miss Price absconded from the ward several times and made multiple attempts to take her own life.
“It should have been updated in those six days [before Miss Price’s death], shouldn’t it,” asked Ms Heaven.
“The care plan should have been updated,” Ms Williams said.
“It’s good medical practice to get everything up to date.”
Ms Williams was asked if staff were given full details of patients’ progress.
“Every Saturday and Sunday I would have a one-to-one with all the Newport West patients and look through their notes and print out copies for a report the next day,” she said.
These notes would be made available to staff ahead of meetings to discuss patients’ progress, and Ms Williams would read out the report to staff ahead of the patient joining them.
Senior Coroner for Gwent Caroline Saunders asked Ms Williams if she was satisfied that Dr Nahla Jamil – a consultant psychiatrist with Aneurin Bevan University Health Board – was aware of an issue around Miss Price attempting to leave the ward and then attempting to take her own life on January 24, 2016. She said she was.
Ms Williams said she was “confident” that Miss Price was not attempting to take her own life every time she absconded from St Cadoc’s.
Ms Saunders asked if there had been any discussions about removing potentially dangerous items from the ward.
“I spoke to my manager about this,” said Ms Williams. “There was nothing we could do.”
Lewis James, a healthcare support worker at the time, said that on the day of Miss Price’s death, the ward at St Cadoc’s was “very busy”.
“There was another patient whose behaviour was escalating.”
“We had another patient threatening to leave,” said Maureen Froude, also a healthcare support worker.
“The ward that morning was really dreadful.”
Ms Froude said she was left to do the level two checks by herself as the other staff were occupied with “escalating” patients.
She saw Miss Price in the corridor at around 1.15pm, and discovered Miss Price’s body at around 1.40pm.
“Sarah was a lovely person but she was very sad on this admission – very little eye contact and hard to engage with. But I had a good rapport with her,” Ms Froude said.
The inquest continues.
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