FAILURE to share information about the suicide risk of a 67-year-old grandmother led to her jumping from the fifth floor of Southmead Hospital, an inquest has heard.
Carolyn Brock, a voluntary patient at the hospital in the Oakwood Ward was found at 11am on August 21 2016, in the atrium of the Brunel Building.
She had applied for local leave, to go out onto the hospital grounds, before going up the lift to the fifth floor.
Mrs Brock had been on medication for anxiety, blood pressure and depression prior to her death, and had also seen a doctor for stress related problems, following her recent retirement, with past incidents of self-harm.
She was admitted to A&E in July 2016 – a month before she had died – after an attempted overdose, which only two years after her son had taken his own life.
She was later warded in the Oakwood Ward in Southmead, which is run by the Avon and Wiltshire Mental Health Partnership NHS Trust.
The hearing heard from Mrs Brock’s psychiatrist Dr Jacek Kolsut and psychologist Dr Mike Evans who both saw her the week she died.
Dr Evans had met her on Wednesday, August 17, when she told him she was "not going to recover" and "wanted to die".
Because of that, he changed her suicide risk from “medium” to “medium-high”, adding that she should not be allowed to leave her ward unescorted.
Both doctors told the court they were concerned staff could be "deceived or be over confident" in Mrs Brock’s mental state when deciding to let her leave the ward.
But her official care plan remained unchanged, and despite Dr Evans interrupting a meeting to discuss the heightened risk, nothing was communicated to the staff working with Mrs Brock.
Only the notes at the end of a patient's file were available to staff.
Melanie Warren, the nurse in charge of the ward, said that she had not been informed about the change in status, which was echoed by other nurses and health assistants who gave evidence.
The trust said on Monday that it would not accept a ruling of neglect, saying there was no gross failure on the part of the trust.
But in her conclusions in Avon Coroners Court today, senior coroner Maria Voisin said that Mrs Brock was “a patient whose risk had increased, and required accompanied leave” and that there had been “a failure to communicate this to staff caring for her”.
She added: "This failure led to her inappropriately leaving on unaccompanied leave which results in her having an opportunity to take her own life."
The flaws were also highlighted in an independent root cause analysis report, which stated that staff were over-reliant on Mrs Brock declaring her mental state, and staff being “unaware” of the increased risk she posed to herself.
The final verdict was deemed suicide with narrative conclusions.