Hospital staff watched a young woman lie dying on the floor for more than an hour because they thought she was asleep, an inquest has been told.
Shannara Donnelly, 22, was supposed to be watched ‘at all times’ after being deemed a risk of self-harm while at Chase Farm Hospital in Enfield, north London.
But medical staff wrongly monitored her using cameras and missed her collapsing in her room at the unit on June 19.
The inquest at George Meehan House in Wood Green heard that when they saw Shannara lying on the floor, they assumed she was sleeping, and she remained there for over an hour.
The hearing, which is expected to last up to two weeks, was told she died ‘apparently by her own hands’.
Shannara, known to her family as Jade, had reported previous sexual abuse, had struggled with alcohol abuse and sometimes heard ‘voices’ in her head, the inquest has heard.
Her mum, Kerry Donnelly, explained that Jade had struggled during lockdown and had recently lost three close members of her family before her death.
She said of her daughter: ‘The pain was sometimes just too unbearable for her. As such, she had stayed in different places whilst she tried to get help and where she would be safe.
‘Tragically, whilst in [the care of Chase Farm Hospital] on June 19, a very beautiful leaf fell from our family tree, but the memories of Jade will remain deep-rooted in our hearts forever.’
The court has heard that despite a note on her health documents stating she shouldn’t be sent to Chase Farm Hospital following a previous incident, Jade was again admitted to the unit after previous stays at St Ann’s Hospital in Haringey.
Area Coroner Tony Murphy read admissions from the Barnet, Enfield and Haringey Mental Health NHS Trust, including that Jade ‘shouldn’t have been sent’ to Chase Farm Hospital, that her risk assessment was inadequate, and that she ‘should have been within eyesight observations’.
The Trust further admitted that necessary safety checks were not carried out by nursing staff at the facility, which was also housing another patient at the time, and that CCTV observations by staff were an inadequate form of observation.
Additionally, no staff on shift were compliant with their life support training and of the two oxygen tanks kept at the unit, one was empty and the other missing an essential attachment.
CCTV footage played to jurors from the day of Jade’s death showed members of staff observing the girl on cameras and through ‘peephole’ windows, but not completing observations required under her level of care.
Mark Pritchard, Managing Director at Barnet, Enfield and Haringey Mental Health NHS Trust, began his evidence by apologising to Jade’s family.
‘I want to offer my sincere condolences, on behalf of the Trust, for the shortcomings in Jade’s death,’ he said.
Mr Murphy took the court through the Trust’s policy guidelines for patients under Level Three care, which Jade was under, which states they should be within sight ‘at all times’.
Guidelines also stated that though CCTV observation could be used to support staff, ‘it should not be used in place of observations and engagement’.
They also stated patients should be observed ‘attentively’.
Mr Murphy asked Mr Pritchard: ‘Does it appear to you that, during the footage you saw, that Jade’s observation was conducted by staff attentively?’
He answered: ‘No, I don’t believe it was.’
Jade’s family’s lawyer, Ross Beaton, later questioned Mr Pritchard on whether Jade’s level of care was provided effectively.
Mr Beaton said: ‘Level Three means being within eyesight unless [the patient] is in the bathroom, in which case you will be in verbal contact [with them].
‘Did you see any Level Three observations [in the CCTV footage]?’
Mr Pritchard replied: ‘The bulk of it, I would say no. The overarching answer is no.’
Jane Basemera, Jade’s allocated nurse on the day of her death, told the court the patient would have lived had she been on Level Four observations.
Ms Basemera, who broke down in tears during her evidence, said: ‘If a patient has [tried to use a] ligature, it should be arm’s length [Level Four care].
‘Arms-length observations would have saved Jade.’
Mr Murphy said: ‘It does appear that some very significant events that occurred to Jade during the time in the bathroom were missed.’
Ms Basemera accepted that this was true, but also spoke of staffing issues at the unit, saying Jade should have had two nurses looking after her.
The nurse admitted she’d been told that Jade was on the floor but hadn’t been told of her collapse.
If she had been told, she said she would have known ‘without a doubt’ that something was wrong, the inquest heard.
The inquest continues.
For emotional support, you can call the Samaritans 24-hour helpline on 116 123, email jo@samaritans.org, visit a Samaritans branch in person or go to the Samaritans website.
If you're a young person, or concerned about a young person, you can also contact PAPYRUS, the Prevention of Young Suicide UK.
Their HOPELINE247 is open every day of the year, 24 hours a day. You can call 0800 068 4141, text 88247 or email: pat@papyrus-uk.org.
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