Hospital neglected woman in hanging tragedy

Maria Evans tried to self-harm or make serious attempts to take her life 20 times in less than a year before she finally succeeded.

The 20-year-old was found on the floor of a bathroom with a dressing gown cord wrapped around her neck in a secure psychiatric unit at Sheffield’s Northern General Hospital. A pathologist gave the cause of death as ligature strangulation.

The Sheffield hearing was told she had previously attempted to put ligatures around her neck in the form of shoelaces and a belt eight times in the weeks before her death on Thursday November 26, 2009.

But her care had been relaxed to round-the-clock five-minute observations days before her death and Sheffield coroner Chris Dorries said there was no evidence she intended to kill herself.

Recording a narrative verdict he said: “While this was a deliberate act it was part of a long series of self-harm incidents and although Maria may have been reckless as to her safety there is no compelling evidence that she intended to die on this particular occasion.

“Maria’s propensity to self-harm was clearly recognised and significant measures had been put in place to protect her life.

“However these measures, frequency of observations and the restriction of items that might form a ligature were not followed on the day of her death despite being clearly set out in the care plan. Accordingly, Maria’s death was contributed to by neglect.”

Consultant psychiatrist Dr Paul Birkett told the inquest Miss Evans, who had been diagnosed with a borderline personality disorder, began self-harming at the age of eight.

She was admitted to the secure unit under the Mental Health Act after she climbed onto a roof and threatened to jump off.

He said people with her psychiatric problems were like “hot potatoes” and their management was “very challenging”.

Dr Birkett said Miss Evans, who was adopted and went to school in Shiregreen and Firth Park, had a “Russian roulette” attitude to life but he was not totally certain she wanted to commit suicide.

She had seemed better in the week before her death and her care was relaxed from constant observations to regular checks.

The psychiatrist said it was not his decision to give Miss Evans a dressing gown with a belt and he had not been informed. Hospital policy was directed more towards saving other patients from harm rather than stopping patients harming themselves.

Despite Miss Evans being under one-to-one observation, she still managed to obtain shoelaces and a cigarette lighter.

But she went for a period of 12 days without attempting to self-harm, the longest in five months, and had been asking about a discharge.

“I was extremely surprised at the subsequent events,” said Dr Birkett.

She had previously swallowed a razor and taken a large overdose of tablets, both of which required medical intervention.

“She probably had the opportunity to repeat either of those acts and she didn’t,” said Dr Birkett.

“That makes me sceptical about whether she understood just how dangerous the use of a ligature was.”

He went on: “She would probably have acknowledged that death was a possible outcome but I think she probably grossly under-estimated the risk that she was taking.”

Kevan Taylor, chief executive of Sheffield Health and Social Care NHS Foundation Trust, said improvements had been made after an internal review following the case.

He said: “We would like to apologise for the events which resulted in Maria’s death.

“The trust recognises the very serious nature of the incident. A comprehensive action plan is now in place in which all of the recommendations have either been addressed or are in progress.”