Woman Killed Herself After South London Hospital Neglect, Coroner Concludes

A female killed herself aft a southbound London psychiatric portion grounded to hunt her possessions adequately, a coroner has concluded.

Michelle Sparman, a individual trainer and telephone dispatcher for nan Metropolitan constabulary from Battersea, south-west London, died connected 28 August 2021 astatine Kingston hospital, 4 days aft trying to return her ain life.

The adjunct coroner, Bernard Richmond KC, concluded that Sparman, 48, died of a hypoxic encephalon injury, determining she had died by “suicide whilst nan equilibrium of her mind was disturbed, contributed to by neglect”.

He wished 4 probable causes of death: her struggles pinch worry and depression, including impulsiveness; a “difficult relationship” pinch her ex-partner, including “intemperate and excessive texting” from him, which called into mobility her intelligence wellness and fittingness to beryllium a mother; her “justifiable feelings of abuse” arsenic a consequence of his behaviour, and inadequate searching connected leaving and entering Rose Ward, a locked 20-bed female-only intelligence wellness portion astatine Queen Mary’s infirmary successful Roehampton.

He cited her perimenopausal symptoms and financial and master problems arsenic imaginable causes.

He said Sparman had presented arsenic a voluntary inpatient successful Rose Ward, pinch clear “red flags” that she was astatine consequence of harming herself.

He added: “The work to protect personification successful a intelligence wellness ward from injuring themself pinch items seems to maine to beryllium a basal responsibility of nan ward.

“The nonaccomplishment to hunt adequately is truthful fundamental, it easy passes nan Jamieson trial [a modular of impervious for a uncovering of neglect successful an inquest] … She did precisely nan point she should person been guarded against.”

Richmond will besides nutrient a prevention of early deaths study looking astatine a request for intelligence wellness wards to present a centralised grounds of each vulnerable items that are connected nan ward, which he plans to taxable to NHS England fixed its imaginable nationalist implications.

Richmond noted nan effect of Sparman’s “difficult relationship” pinch her ex-partner Roger Stephens, and though he felt location was “no uncertainty a awesome woody of emotion betwixt them”, nan narration gained a “certain toxicity”.

He added that Stephens’ messaging constituted harassment and near Sparman emotion “trapped”, but he did not judge this was done “deliberately”.

Over 5 days of grounds successful May, Inner West London coroner’s tribunal heard really Sparman’s intelligence wellness deteriorated aft nan breakdown of her 28-year narration successful January 2020.

In texts sent to her siblings, Sparman said she could “end up sidesplitting myself” complete Stephens’ consequent behaviour.

Stephens told Richmond that “in hindsight I should not person sent truthful galore texts”, and agreed that they were “very angry” and had “put accent connected her”.

On 21 August 2021, Sparman was taken to infirmary aft Stephens recovered she had taken an overdose and self-harmed. Sparman was put successful nan “red zone” category, meaning she was expected to beryllium searched for harmful items.

Ward head Meredith Kuleshnyk, who recovered Sparman, said lessons had been learned including much unit training astir searches and a hunt room being made available.

Although he acknowledged nan staffing pressures nan ward was under, Richmond wished that nan absence of record-keeping was “a profoundly worrying authorities of affairs”. Despite grounds suggesting Rose Ward’s practices had changed, Richmond said he was not satisfied that a “robust signaling system” was now successful place.

Jennifer MacLeod, nan lawyer representing nan family, cited statistic showing that successful Rose Ward, successful 2020, location were 70 instances of self-harm – indicating that unit intervened earlier termination could beryllium attempted.

Kuleshnyk besides told nan inquest that she planned to talk home maltreatment pinch Sparman aft watching her relationship pinch Stephens.

In a self-referral to Talk Wandsworth, a talking therapy service, Sparman stated that Stephens’ behaviour “has impacted connected my sleep, my eating, my confidence, my affectional and intelligence wellbeing”.

Shaun Case, Sparman’s half-brother, said shespoke of “anxiety, tightness successful her thorax erstwhile his [Stephens’] sanction came up connected her phone”, and that she feared him turning up astatine her flat.

MacLeod said: “The family’s position is that she perceived that arsenic abuse, and each nan aesculapian professionals we person heard from perceived that arsenic abuse.”