We have the verdict of The Coroner's Court into the death of Charlotte Oldman - unsurprisingly this puts the blame on the negligence of The Abraham Cowley Unit.
This report is again from 'Get Surrey';
Lightwater woman's attempted hanging was not suicide bid, coroner rules
By Fergus McEwan
A Lightwater woman, who died after trying to take her own life by hanging in a mental health hospital ward, was "severely unwell" but not intent on committing suicide, a coroner has concluded.
Dr Karen Henderson, assistant coroner for Surrey, said it "could not have been predicted" by staff at the specialist Abraham Cowley Unit (ACU) in Chertsey Charlotte Joy Oldman would wrap a pay phone wire around her neck a day after she was admitted on April 24, 2014.
However, Mrs Henderson criticised Surrey and Borders Partnership NHS Foundation Trust (SABP) for a lack of security at the unit which allowed the 29-year-old to gain access to the phone, concluding she would otherwise "not have died when she did" from what she described as an "impulsive act".
During a two-day inquest at Woking Coroner’s Court held over Tuesday and Wednesday (September 29-30), the court heard Mrs Oldman was discovered in a room which should have been locked.
She went into cardiac arrest and was resuscitated several times before being pronounced dead at 2.45am on April 26.
Mrs Oldman had suffered mental health problems since she was a teenager and was frequently treated for the effects of self-harming.
These included cuts, burns, overdoses and attempted hangings which her husband, Thomas Oldman, said she used to drown out voices in her head.
In the last three years of her life, she had three lengthy stays on psychiatric wards.
On the third occasion, she was discharged in February 2014 with a community care plan which Mr Oldman claimed was not co-ordinated properly, leaving her feeling "abandoned".
'Voices'
“I have no doubt Charlotte was severely psychologically unwell in 2011, and there was no significant improvement in her illness in the last few years of her life,” said Dr Henderson.
“That’s not to say there was not a desire to get better, and some days were better than others.
"But much of her last few years were filled with prolonged stays in psychological facilities to keep her safe and attempt to instill coping strategies.
“A common thread through her last years were her frequent self-harming activities, brought about by voices in her head or exposure to challenging circumstances.
"Charlotte was warned of the dangers of these episodes.”
The coroner said the treatment Mrs Oldman received leading up to her discharge in February 2014 was "entirely appropriate" and that she was "the best she had been for some considerable time", adding that Mrs Oldman "felt she had a future".
Mrs Henderson said the breakdown in her community care was "regrettable and should not have happened", but found that Mrs Oldman had "remained stable" and a lack of contact with her carers did not contribute to her death.
She found the "trigger" for Mrs Oldman’s admission to the ACU was the news a job offer as a healthcare worker had been rescinded because Mrs Oldman, a trained nurse, had been temporarily suspended over fears over her mental health.
“I’m satisfied her admission to the ACU was entirely appropriate for her safety, which was the most important thing to her family,” said the coroner.
The court heard on April 25 last year, Mrs Oldman had responded positively to an assessment at the ACU shortly before she hanged herself.
She had agreed to stay at the ward for further support and had been granted temporary leave to spend time with her husband.
'Tragic death'
“There was a long history of self-harming behaviour but, at that point in time, I don’t find that what Charlotte did could have been foreseen or predicted,” said Dr Henderson.
“Given her history, it was likely she would self-harm again, but it was not predictable at that point.
"In a short period of time, she took the opportunity to tie a ligature around her neck and died as a result of that act.
She added: “I don’t accept Charlotte wished to end her own life. Her actions followed a pattern of using ligatures as a sign of distress. This was a constant feature of her illness.
“There was no evidence that presented itself at the time of her death that she was at immediate risk.
"It was an impulsive act, but there is not sufficient evidence that she meant to take her own life. She died from a self-inflicted injury, but her intention is unclear.”
Dr Henderson said SABP had acknowledged the phone room should not have been left unlocked and the fact it was had contributed to Mrs Oldman’s death.
She added: “Nevertheless, this was the tragic death of a very vulnerable and severely unwell young lady. I conclude that, but for the phone room being open, she would not have died when she did.”
During her summing up, the coroner said she was "troubled" after hearing staff at the ACU had identified the pay phone as a hanging risk a year earlier in 2013, yet "no appropriate measures were put in place to reduce or eliminate that risk".
“There should have been active steps to remove the risk,” she added. “It took the death of a very vulnerable and ill person for these steps to be taken.”
That does say it all really - on its own it would be bad but in the context of so many other incidents it is a disgrace.
Neil Harris
(a don't stop till you drop production)
Home: helpmesortoutstpeters.blogspot.com
Contact me: neilwithpromisestokeep@gmail.com
Dr Karen Henderson, assistant coroner for Surrey, said it "could not have been predicted" by staff at the specialist Abraham Cowley Unit (ACU) in Chertsey Charlotte Joy Oldman would wrap a pay phone wire around her neck a day after she was admitted on April 24, 2014.
However, Mrs Henderson criticised Surrey and Borders Partnership NHS Foundation Trust (SABP) for a lack of security at the unit which allowed the 29-year-old to gain access to the phone, concluding she would otherwise "not have died when she did" from what she described as an "impulsive act".
During a two-day inquest at Woking Coroner’s Court held over Tuesday and Wednesday (September 29-30), the court heard Mrs Oldman was discovered in a room which should have been locked.
She went into cardiac arrest and was resuscitated several times before being pronounced dead at 2.45am on April 26.
Mrs Oldman had suffered mental health problems since she was a teenager and was frequently treated for the effects of self-harming.
These included cuts, burns, overdoses and attempted hangings which her husband, Thomas Oldman, said she used to drown out voices in her head.
In the last three years of her life, she had three lengthy stays on psychiatric wards.
On the third occasion, she was discharged in February 2014 with a community care plan which Mr Oldman claimed was not co-ordinated properly, leaving her feeling "abandoned".
'Voices'
“I have no doubt Charlotte was severely psychologically unwell in 2011, and there was no significant improvement in her illness in the last few years of her life,” said Dr Henderson.
“That’s not to say there was not a desire to get better, and some days were better than others.
"But much of her last few years were filled with prolonged stays in psychological facilities to keep her safe and attempt to instill coping strategies.
“A common thread through her last years were her frequent self-harming activities, brought about by voices in her head or exposure to challenging circumstances.
"Charlotte was warned of the dangers of these episodes.”
The coroner said the treatment Mrs Oldman received leading up to her discharge in February 2014 was "entirely appropriate" and that she was "the best she had been for some considerable time", adding that Mrs Oldman "felt she had a future".
Mrs Henderson said the breakdown in her community care was "regrettable and should not have happened", but found that Mrs Oldman had "remained stable" and a lack of contact with her carers did not contribute to her death.
She found the "trigger" for Mrs Oldman’s admission to the ACU was the news a job offer as a healthcare worker had been rescinded because Mrs Oldman, a trained nurse, had been temporarily suspended over fears over her mental health.
“I’m satisfied her admission to the ACU was entirely appropriate for her safety, which was the most important thing to her family,” said the coroner.
The court heard on April 25 last year, Mrs Oldman had responded positively to an assessment at the ACU shortly before she hanged herself.
She had agreed to stay at the ward for further support and had been granted temporary leave to spend time with her husband.
'Tragic death'
“There was a long history of self-harming behaviour but, at that point in time, I don’t find that what Charlotte did could have been foreseen or predicted,” said Dr Henderson.
“Given her history, it was likely she would self-harm again, but it was not predictable at that point.
"In a short period of time, she took the opportunity to tie a ligature around her neck and died as a result of that act.
She added: “I don’t accept Charlotte wished to end her own life. Her actions followed a pattern of using ligatures as a sign of distress. This was a constant feature of her illness.
“There was no evidence that presented itself at the time of her death that she was at immediate risk.
"It was an impulsive act, but there is not sufficient evidence that she meant to take her own life. She died from a self-inflicted injury, but her intention is unclear.”
Dr Henderson said SABP had acknowledged the phone room should not have been left unlocked and the fact it was had contributed to Mrs Oldman’s death.
She added: “Nevertheless, this was the tragic death of a very vulnerable and severely unwell young lady. I conclude that, but for the phone room being open, she would not have died when she did.”
During her summing up, the coroner said she was "troubled" after hearing staff at the ACU had identified the pay phone as a hanging risk a year earlier in 2013, yet "no appropriate measures were put in place to reduce or eliminate that risk".
“There should have been active steps to remove the risk,” she added. “It took the death of a very vulnerable and ill person for these steps to be taken.”
That does say it all really - on its own it would be bad but in the context of so many other incidents it is a disgrace.
Neil Harris
(a don't stop till you drop production)
Home: helpmesortoutstpeters.blogspot.com
Contact me: neilwithpromisestokeep@gmail.com
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