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17
Jul
Alleged public service failures highlighted at Harrogate woman’s inquest
An inquest into the death of a Harrogate woman has highlighted alleged gaps in how the hospital and police dealt with the situation.
The two-day inquest into the death of Ellen Francesca Anderson, who died aged 26 on June 30 last year, opened at Northallerton coroners court today.
Ms Anderson died shortly after disappearing from Harrogate District Hospital where she had been taken following an attempted overdose.
Today's hearing focused on the response of the hospital and police.
The court heard Ms Anderson was taken to the hospital, which is run by Harrogate and District NHS Foundation Trust, by her mother after consuming a concoction of medication and alcohol.
After arriving, a nurse, who gave evidence in court today, undertook a triage assessment to judge the level of risk.
Triaging is standard practice across hospital emergency departments and aims to ascertain patients’ priority for treatment based on their current state.
The nurse, who had been working at the hospital for 18 years at the time, concluded Ms Anderson was of category three risk and a “moderate risk of self-harm”.
This means she was not required to receive urgent medical treatment, but should have been seen within an hour of the assessment being completed.
The nurse told the inquest Ms Anderson was “drowsy” at the time of her assessment and “was not engaging much” with her.
Despite knowing Ms Anderson had attempted to overdose – and describing her mood as “low” – the nurse could not recall asking Ms Anderson or her mother whether she had struggled with her mental health before, the court heard.
In addition, the nurse told the court she “did not have access” to WEBV – on online software used to store medical records – at the time of the incident. This meant she could not access Ms Anderson's medical records at the time.
The court later heard from Amy Carr, the matron of nurses at the hospital, who was not working at the hospital at the time.
However, following an audit, Ms Carr said WEBV was available at Harrogate hospital at the time, but was “not commonly used in the emergency department”.
Staff ‘heard patient crying’
The nurse said Ms Anderson became “upset” during the assessment after being told she needed to have a blood test. She was “scared of needles” and “wanted to leave the hospital”, the court heard.
However, the nurse eventually moved Ms Anderson into a private cubicle to “sober up and sleep”.
The court heard the nurse, and other doctors, later reported hearing Ms Anderson crying from the cubicle.
The nurse said:
She wasn’t hysterical, but I could hear her crying. Other members of staff said they heard her crying too.
The court heard the nurse did not feel Ms Anderson was a harm to herself or to others at the time, and did not refer her to the mental health team.
The nurse also said:
My understanding of overdoses is only to refer people for a mental health assessment if they are medically fit to do the assessment. Ellen was not fit to do the assessment.
I did not hear anything that indicated she would harm herself further, nor did I hear her ask her mum to ‘take care of her son’ in the future – indicating she would harm herself.
Most triage actions were ‘completed’
Dr David Earl, a consultant and deputy medical director at the hospital, also gave evidence in court today.
Dr Earl said there was a “missed opportunity to ask questions in the triage”, but added he, and the medical panel, felt actions were still “completed” during the assessment.
He said:
The whole point of the triage is to ascertain how best to manage the patient. We felt most of the actions were completed.
For somebody who is tired and distressed – although that sounds contradictory – the cubicle was an appropriate place to put her. But, the mental health referral should have gone in at the time.
Dr Earl added he and the panel concluded Ms Anderson was "of capacity" to leave the premises at the time.
His definition of "capacity" is a patient understanding the implications of what could happen to them, should they choose to leave the hospital without being assessed. He said:
There was nothing that made us think she lacked capacity. It’s not just a tick-box exercise – there’s much more to it.
A patient has the right to make unwise decisions. But there was clearly mental health underlying in Ellen’s case, and that should have been assessed.
Police involvement
Ms Anderson left the hospital and went missing the following morning.
The court heard Ms Anderson’s mother told a nurse she was “not in her cubicle” around 7am the next day. Her mother had returned with Ms Anderson after having a cigarette outside the hospital, but she then absconded.
It has not yet been established where Ms Anderson went or how she came to her death.
After this, a nurse reported Ms Anderson missing to North Yorkshire Police. The court heard it is common practice to report incidents of this nature to the police.
Inspector Jonathan Asvadi, who was the police's force incident manager at the time, told the court he was responsible for prioritising resources across the county and logging the highest risk cases.
But the force declined to dispatch officers to assist in finding Ms Anderson.
Instead, the dispatcher allegedly told the nurse to “send an ambulance” – despite Ms Anderson’s whereabouts being unknown.
Inspector Asvadi said the decision was made due to there being “no indication” that Ms Anderson wanted to harm herself further.
Around 8am, an officer called the hospital back, the court heard. Inspector Asvadi said this was to “get an update” – adding the procedure is “not uncommon”.
We needed to satisfy ourselves, honestly.
He admitted there was “no value” in the dispatcher advising an ambulance be sent to an unknown location.
Inspector Asvadi told the court:
The communications team have set questions and they undergo extensive training to even be able to answer the phone.
They are incredibly professional, caring and inquisitive.
Inspector Asvadi now works for Humberside Police, which has since established the Right Place, Right Care programme.
He told the court this helps public service agencies decide how responsibility is assumed in emergencies.
An official cause of death has not yet been established, but Ms Cundy did say the evidence presented today “indicates suicide”.
The inquest is expected to conclude tomorrow.
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