Lessons of sister’s death ‘not learned fast enough’

[Alison J Stevens]

Lessons of sister’s death ‘not learned fast enough’

Saturday, June 25, 2011

Leicester Mercury

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Mental health service bosses did not learn lessons quickly enough after a woman hanged herself in her hospital room, her brother says.

Simon West, of Wigston, said changes should have been put in place following his sister Helen Clinton’s death which could have saved the life of another patient, teenager Kirsty Brookes.

Kirsty, 19, of Loughborough, was found hanged a few weeks after Helen.

She had left the ward on her own – something staff should not have allowed her to do.

The two women were both patients on Heather ward at the Bradgate Unit, on the Glenfield Hospital site.

Mr West said: “All that my family and I asked for after Helen’s death was that lessons were learnt so it never happened again.

“We find it an incredibly sad situation that this doesn’t seem to have proved to be the case.”

Mother-of-two Mrs Clinton, 44, of Wigston, hanged herself on Heather ward on April 4 last year.

Mr West said: “When I read the recent report of Kirsty’s inquest, there seemed to be so many similarities to my sister’s case.

“There appeared to be a lack of communication between staff on the ward, a lack of hand-over notes and lack of adequate observation of patients.

“Surely, the trust should have learnt the lessons of what happened to Helen? Even if there hadn’t been time for a formal inquiry to be put in place, you would have thought immediate precautions would have been taken and staff would have been more alert.

“Surely, there would have been increased observation levels and commitment to the patients, especially on that ward.

“I accept mistakes happen but I find it unforgivable there should be two such similar incidents so close to each other.”

The Bradgate Unit is run by Leicestershire Partnership NHS Trust.

Jackie Ardley, chief nurse at the trust, said changes had been made after both Helen and Kirsty’s deaths.

Nobody was available yesterday to say what changes had been made after Helen’s death.

But the trust has previously said the changes made following Kirsty’s death included improving communication between the ward teams, completing patient records to a higher standard, giving staff more training and supervision and reassessing and updating policies and procedures.

Ms Ardley said: “The well-being and safety of people in our care is paramount.

“I want to reassure our service users and their families that lessons are learned following tragic incidents.

“We would be very willing to meet with Mr West and his family again and provide him with assurances that changes were implemented following his sister’s death and also to reassure him that ward staff are alert at all times to the risks and clinical needs of patients.”

MY THOUGHTS

Two young Women die within weeks of one another, on the same Hospital ward.

An 18 year old girl was found hanged in her room, after Nursing staff failed in their duties to monitor patients at regular intervals.

The tragedy happened after another 44 year old woman hanged herself weeks earlier.

After the first death,the hospital should of tightened the security of their patients, preventing another tragedy.

Reasons given was the failure of Nursing staff to provide adequate handovers at the change of each shift,lack of communication between Nursing staff.

The chief Nurse at the hospital, stated that lessons have now been learned.

Two young Woman have died needlessly due to incompetence.

Senior Nurse Jackie Ardley said, I WANT TO REASSURE OUR SERVICE USERS AND THEIR FAMILIES THAT LESSONS ARE LEARNED FOLLOWING TRAGIC INCIDENTS.

I would not be happy to leave a member of my family at this hospital.

Like Social Services and their serious case review, nothing seems to be learned from past mistakes, in this case only time will tell.

 

http://www.thisisleicestershire.co.uk/Lessons-sister-s-death-learne...