Report by Tom Wright , Reporter
Monday, April 16, 2012
A WESTON woman suffocated herself on a mental health hospital ward days after telling staff she feared people wanted to torture and kill her.
Stephanie Clarke, aged 39, locked herself in a shower room at Southmead Hospital in Bristol and tied a carrier bag over her head, Flax Bourton Coroners Court was told.
Staff, who were meant to check on her every 10 minutes, thought she was making progress.
But on the day she died a routine check, timed at 10.20am, was recorded as being carried out - even though she was receiving emergency resuscitation from staff in the shower room at the time.
Ms Clarke had attended Weston General Hospital in the days leading up to her death and admitted to suffering from paranoid fears and slashing her own wrists.
After being released she was assessed at her parents’ home in Wingard Close, Uphill, and was taken to Oakwood Ward voluntarily.
Ms Clarke called her parents on June 9 and they thought she seemed unhappy and decided to visit her.
The court was told they arrived at the hospital just after 10am and saw Stephanie was missing.
When they approached a member of staff they were told no-one knew where she was.
But within a quarter of an hour she was found in the shower room.
Hayley Johnson, who was monitoring patients on the ward the day Stephanie died, said: “I saw her lying motionless on the floor. She had a blue Tesco bag covering her head.
“She wasn’t breathing, her face was purple and pale in appearance and there weren’t any signs of movement from Stephanie.”
The court was told Ms Clarke had cut her wrists, four times on each side, in the days leading up to her death.
Despite the cuts and Stephanie admitting she was having paranoid thoughts, staff were happy with her progress as she engaged with other patients on the 19-bed ward.
Jackie Hole, the ward’s matron, said staff were considering reducing checks to an hourly basis because she was not considered a suicide risk.
But on the day she died staff were still meant to visit her every 10 minutes and one member of staff signed to say they had checked Ms Clarke in her room at 10.20am – five minutes after CPR and resuscitation attempts in the shower room opposite had begun.
Ms Hole said the signature on the chart has never been deciphered and said a subsequent review had changed hospital observation checks.
She added the error had no affect on Ms Clarke’s death.
Assistant deputy coroner, Gail Elliman said at the inquest, held on April 4: “The medical cause of death I will record simply as asphyxiation.
“Ms Clarke had a history of depression and self-harm. She took her own life while suffering from a mental illness.”