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Rachel Jones: Senior Coroner concludes death caused by neglect where mental health hospital failed to realise that suicidal inpatient had left the hospital and not returned

The Senior Coroner for West Sussex ruled that Rachel Jones’ death was contributed to by neglect in circumstances where hospital staff allowed her to leave for 15 minutes for a cigarette, and then failed to realise when she did not return for more than three hours. Tragically, during that time, Rachel went to a train line, lay down on the tracks, and was hit by an oncoming train. As staff did not realise that Rachel had not returned, they failed to trigger the Absent Without Leave (AWOL) procedure, which the Senior Coroner found would probably have saved her life.

Rachel Jones was a much-loved daughter, sister and mother. Unfortunately, she suffered a deterioration in her mental health which led to her being sectioned at Langley Green Hospital (LGH).

On 23rd April 2022, Rachel’s family took her to A&E at East Surrey Hospital (ESH) due to suicidal thoughts and superficial cuts o her wrists. She was admitted to ESH and, following a Mental Health Act Assessment on 26th April 2022, was detained under s.2 of the Mental Health Act and transferred to LGH. On admission to LGH on 29th April 2022, the clerking doctor recorded that she had psychotic symptoms and placed her on intermittent observations.   

By 5th May 2022, Rachels’ condition appeared to have improved and she was taken off section. The plan was to discharge her the next day. However, later that afternoon, she was assessed by a Recovery Worker from the alcohol and drugs charity, Change Grow Live (CGL), during which she stated that she was going to hang herself upon leaving the hospital. The Recovery Worker reported this to one of the nurses, but no action was taken. In particular, her risk assessment was not updated.

Shortly afterwards, Rachel was signed out for 15 minutes but did not return at the agreed time. The hospital did not realise she was missing for around one hour. Rachel eventually turned up at her mother’s house, and hospital staff had to drive there to bring her back. Her mother reported that she was agitated and distressed, claiming she had tried to kill herself twice last night in the hospital. Again, the risk assessment was not updated.

The next day, on 6th May 2022, the hospital received an email from Rachel’s mother, expressing concerns about the plan to discharge her, given her suicidal ideations. A nurse spoke with Rachel and she agreed to stay as a voluntary inpatient over the weekend. The hospital also received an email from the Recovery Worker at CGL, reiterating her concerns from the day before.

Nevertheless, at 10:40am Rachel was signed-out for 15 minutes for a cigarette break. After initially going to reception, Rachel went back to the ward door and asked a member of staff for some money. This was a ‘red flag’ and the Nurse in Charge should have been informed, but this did not happen. Rachel then left the building and did not return at 10:55, her agreed time. Staff did not realise Rachel had not returned to the hospital until the police arrived at 14:30, more than three hours later. The Senior Coroner found that this was a serious failing. As a result, the AWOL procedure was never triggered and no steps were taken to find her.

In the meantime, Rachel turned up at a friend’s house. She was behaving very strangely, and her friend drove her back to LGH and dropped her outside at 11:50. Tragically, Rachel did in fact go back into the hospital and briefly spoke with the receptionist before leaving again but, because the AWOL procedure had not been triggered, the receptionist did not know that she was technically a missing patient.  

The Senior Coroner found that there were the following missed opportunities that were possibly causative:

  1. To respond appropriately to the report on 5th May 2022 by a member of staff from Change Grow Live that Rachel intended to hang herself upon discharge.
  2. To update the risk assessment with the concerns of Change Grow Live and from Rachel’s mother following the events of 5th May 2022.

And that the following failures were probably causative:

  1. To notify the Nurse in Charge when Rachel returned back to the ward on 6th May 2022 (asking for some money) so she could be reassessed by the nurse.
  2. To check on Rachel’s whereabouts when she did not return from leave on 6th May 2022.
  3. To follow the AWOL Policy on 6th May 2022.

As a result of the above, she concluded that Rachel’s death was contributed to by neglect.

The family was represented by Matthew Turner instructed by Catherine Knight of Irwin Mitchell. 

The Coroner was HM Senior Coroner for West Sussex, Brighton & Hove, Ms Penelope Schofield.  

The other Interested Persons were Sussex Partnership NHS Foundation Trust (SPFT) and Surrey and Borders Partnership (SABP).