A 25-year-old Larne woman who hanged herself at a secure hospital, 350 miles from home, died after a number of shortcomings in her care, an inquest has found.
Cara Walls, a mental health patient at the Emerald Ward, at Rampton Secure Hospital, in north Nottinghamshire, was found dead on the floor of her room with a ligature around her neck on February 5 2016.
The inquest found that she did not intend to take her own life.
The 25-year-old’s mother, Deirdre Robinson, instructed expert civil liberties lawyers at Irwin Mitchell to investigate how her daughter came to die despite being under regular observations because of her risk of self-harm.
Today, following a seven-day inquest at Nottingham Coroner’s Court, a jury concluded that the ward where Cara was a patient was operating below the prescribed staffing numbers and that this led, on occasion, to observations being missed.
The jury found that Cara was not observed at 15 minute intervals as required by her care plan; information about Cara’s state of mind was not passed on to incoming staff; following a request for mechanical restraint and after taking medication, it was not communicated to ward staff that Cara should be reassessed before returning to her bedroom; issues regarding carrying out observations should have been identified by Rampton following the death of a patient in August 2015.
The jury further concluded that although it was not possible on the evidence to say that these shortcomings contributed to her death, they may have done so.
Fiona McGhie, an expert civil liberties lawyer at Irwin Mitchell, representing Car’a mother Deirdre Robinson, said: “Cara’s death raised some troubling questions regarding the care she received at Rampton Secure Hospital.
“It is a relief for Deirdre that she now has the answers she has waited so long for, even though they paint a vivid picture of Cara’s last hours at the facility, something that no parent should have to face. Of particular concern to her is the fact that the ward was understaffed on the day of Cara’s death and the impact that may have had on the care which she received.
“We sincerely hope that lessons are now learned so that others don’t suffer as Cara did, or as her family continue to do.”
Deirdre had been concerned about how Cara came to be sectioned in Rampton, some 350 miles away from home, as well as how she came into possession of a ligature.
Deirdre said: “Nothing can bring Cara back to me, but I hope that now failings have been identified, that they can be swiftly addressed so other parents can be spared the torment of losing a child in this way.
“No other parent should get a call to hear their child has died at Rampton. Lessons must be learned and I want that to be Cara’s legacy.”