Inquest into the death of Kimberley Lindfield

05.02.15 | |

The inquest into the death of Kimberley Lindfield in Wythenshawe Hospital in Manchester has recorded a narrative conclusion of death by misadventure contributed by neglect and lists a series of serious and significant failures related to appropriate clinical action and the continued health and safety of Kimberley upon her last admission to hospital. 


Kimberley Lindfield was aged 27 at the time of her death and suffered from long-standing mental health difficulties. She had a history of self-harming and attendant self-referral to hospital. Kimberley presented at A&E on 17th July 2012 having taken an overdose of medication having previously been admitted at the end of June 2012.


At no time during her admission and subsequent transfer to the acute medical unit was Kimberley referred for a mental health assessment, as per the protocol stated by the University of South Manchester NHS Foundation Trust Hospital and the Manchester Mental Health and Social Care NHS Trust to have been in place at the time.


The latter had been confirmed to the Senior Coroner, Mr Nigel Meadows, in a joint response to a previous rule 43 letter following the death of another patient in the Wythenshawe Hospital in 2010 and prior to Kimberley’s death.


Kimberley was found hanging by a dressing-gown cord in her bed space on the acute medical ward with the curtains partially closed. Despite being resuscitated she died on 23rd July 2012. Expert evidence was given to the court as to the nature of Kimberley’s mental health condition and her attendant coping strategies.

The Senior Coroner has written a regulation 28 report, raising key areas of concern, including inter alia the absence of any written policy or protocol as to what a particular level of observations would entail where concerns had been raised about a patient’s mental state and/or self-harming behaviour.

The need for auditing processes to ensure that appropriate referrals and timely responses for mental health assessments were in fact being made has also been raised.


The Senior Coroner also criticised the internal investigation, in particular the failure to interview key members of staff following Kimberley’s death.


Kimberley’s family were represented by John Hobson, Doughty Street Chambers and Claire Liptrot, Nelsons solicitors

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