Thursday, 1 October 2015

Another death at the Abraham Cowley Unit.

I started this Blog over concerns I had about treatment at the Accident and Emergency department at St. Peter's Hospital. Later, it became clear that there are also serious problems at The Abraham Cowley unit which is on the same site but is run by a separate NHS mental health trust.

There have been a series of absconders, which in some cases have resulted in deaths.

There have been suicides.

All of this has been happening at a unit which is supposed to be safe and secure for vulnerable patients.

There is now yet another inquest into a death at The Abraham Cowley Unit, here reported in 'Get Surrey' on 30th September 2015;

Woman who made attempt on her own life in hospital felt 'abandoned' by carers, inquest hears

Charlotte Joy Oldman, from Lightwater, died two days after being admitted to St Peter's Hospital

Woking Coroner's Court

Inadequate security measures at St Peter’s Hospital in Chertsey failed to prevent a Lightwater patient from trying to take her own life, an inquest has heard.
Charlotte Joy Oldman, 29, was admitted to the Abraham Cowley specialist mental health unit on April 24 last year.
Staff were told she had a history of mental illness and self-harm and had on many occasions been treated for overdosing on medication.
Mrs Oldman was able to get into a room with a pay phone, which should have been locked, and hanged herself with the phone wire on the afternoon of April 25.
She went into cardiac arrest and was resuscitated several times before being pronounced dead at 2.45am on April 26.
At the opening of an inquest at Woking  Coroner’s Court on Tuesday, the court heard from Stephen Plant, manager of the ward where Mrs Oldman died.
Mr Plant admitted the risk posed by the phone had been highlighted a year earlier, but there was no accountable system for the use of the room.
He revealed staff were instructed to keep the phone room locked when not in use, but the key was left unsecured in an office and no record was kept of who used it.

Despite checking with the staff on duty that day, he was unable to tell the court who unlocked the room prior to Mrs Oldman’s suicide attempt.

He said it was the duty of any member of staff who allowed a patient to make a phone call to assess the risk they posed and to make sure the room was locked again afterwards.

He said staff carried out hourly checks on the patients and the ward "environment" but admitted this did not include checking whether secure areas were locked.

This meant the phone room could have been unlocked "for some time" before the incident, he added.
Karen Henderson, assistant coroner for Surrey, asked Mr Plant: “You are unable to tell me that there was any control over that phone room, is that correct?”
He replied: “My understanding was that staff carrying out the hourly checks were going to each area in the ward, but that was obviously not happening.”
Asked whether Mrs Oldman might still be alive if a reliable system had been in place, Mr Plant said: “If she had not had access to that room, she would not have gone in there unseen and this tragedy would not have happened.”
The ward manager said the phone room had been decommissioned following Mrs Oldman’s death and an "awful lot of work" had taken place in the ward to remove any item that could pose a hanging risk.
Patients were now given hands-free phone sets to make calls, he explained.
“Can you tell me why it needed the death of Charlotte Oldman to bring about these changes?” Mrs Henderson asked him.
“No,” he responded. “I can’t answer that. I’m sorry.”
The court also heard from Mrs Oldman’s husband, Thomas, who said she had been "agitated and frustrated" after two months of care in the community, which he claimed was poorly planned, with several missed appointments and a lack of contact.
“Charlotte felt abandoned,” he said. “She had her hopes raised that her previous hospital admission would be her last, but was left feeling despondent and isolated from the people she was supposed to be able to rely on.
“It was her long-term goal to be responsible for her own care, but she was forced to take ownership of it very acutely rather than being guided there.
“She could roll with the punches of one missed appointment, but even that left her feeling very unsettled.”
The inquest continues.


I've used the 'Get Surrey' report because it avoids sensationalism, unfortunately it also fails to report on a very serious incident in the Inquest itself which was reported in The Daily Mirror;
Coroner Karen Henderson quizzed the ward manager Stephen Plant on why the phone booth was left unlocked.
Mr Plant told the court an email was sent out years prior to the tragedy instructing staff to make sure the phone booths were locked as part of their routine hourly checks.
However, giving live evidence, he admitted he did not know why the door was unlocked, who unlocked it and who should have checked.
The coroner said: "How can you stand there as the ward manager and say you do not know who unlocked it, who last used the phone, or who should have checked it?"
In response Mr Plant leaned back in the witness box seat, turned away from the coroner and smirked, before he was reprimanded by the coroner.
She said: "This is a court of law. You do not behave in this way. You are at risk of being in contempt of court if you do not conduct yourself properly. It will not be tolerated.
"Somebody has died."
She then indicated for his solicitor to "explain to him how to behave" and ordered the court to rise for 10 minutes while this took place.
When he returned Mr Plant apologised for his actions and said a number of steps had been taken since a serious incident report of the tragedy.

It is a remarkable situation when the Ward Manager responsible when a patient has died is threatened with imprisonment by the Coroner for his potentially contemptuous attitude towards the Inquest.

There should also be other, more serious concerns.

Over a year ago, in the light of two serious incidents in April 2014, the director of Mental Health Services at The Abraham Cowley Unit assured 'Get Surrey' that security at the Unit was "improving".

At that time he neglected to mention the alleged suicide of Charlotte Oldman only days before.

It's very unfortunate that this tragic death has only become public knowledge some 18 months after it happened; it prevents any accountability by the public.

Here's what was said in 2014;

'Get Surrey' 3rd may 14

The director of mental health services at the Surrey and Borders Partnership NHS Foundation Trust has said the numbers of patients wandering off at the ACU has steadily reduced

Security levels at a mental health unit in Chertsey are said to be improving, despite two worrying incidents in April.

The Abraham Cowley Unit (ACU), based in the grounds of St Peter's Hospital, has had issues in the past with patients going missing, although most return unharmed.

In one recent incident a patient was talked down from a bridge over the M25 in Green Lane, Chertsey, by a passer-by. Just two days later, another patient was coaxed down from a roof in the hospital grounds, prompting concerns over security at the unit.

However, Andy Erskine, director of mental health services at the Surrey and Borders Partnership NHS Foundation Trust, which runs the ACU, said that despite these two incidents, the numbers of patients wandering off had steadily reduced during the past three years, even though more people were using the service.


This statement to the press followed two inquests which you can read about on the 'pages' index on the right hand side of my Blog. As ever, when something goes wrong, the delay in revealing the incident is such that the managers can say that everything has changed since then......until the next inquest.

There have been too many incidents for this hospital to be considered a 'place of safety' so I'll report on the decision of the Inquest and then continue to publicise any information I have about the Unit.

Neil Harris
(a don't stop till you drop production)

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