Jim Duffy has appeared for the family of Joyce Patterson at her inquest. Mrs Patterson died on 8 November 2017 having being struck by a train shortly after absconding from St Helier Hospital in South London. The Assistant Coroner for Inner West London, Darren Stewart, accepted the submission that Mrs Patterson’s death was “contributed to by neglect”.
Jim was instructed by Fiona Huddleston of Leigh Day.
Background
Mrs Patterson was admitted to St Helier via Accident & Emergency on 2 November 2017 having been found at Mitcham Junction station following an overdose of prescription drugs. She was treated for the physical effects of the overdose before being transferred to a psychiatric assessment unit at Springfield Hospital in Tooting, South London on the evening of 7 November. Ultimately, her assessment could not take place due to a deterioration in her physical condition, meaning she had to be transported back to St Helier.
Mrs Patterson was transferred from Accident & Emergency to the Surgical Assessment Unit at around midnight on 8 November. She was not due to undergo surgery, but there were bed constraints at the hospital. She had been escorted by a health care assistant (HCA) from Springfield, but the HCA left in the early hours, leaving Mrs Patterson without an escort or any 1:1 supervision.
At around 11.10 that morning, Mrs Patterson attempted to leave the ward, telling an HCA that an ambulance was waiting for her. The HCA told her to return to her room but did not tell any of her colleagues what had just occurred.
Ten minutes later, Mrs Patterson attempted to leave for a second time. She was pursued by the HCA and by her designated nurse. They were unable to persuade her to stop. Mrs Patterson left the hospital grounds and made off in the direction of Carshalton. The supervising nurse gave evidence that she had not been trained in the physical restraint of patients.
Security were called but said they could not do anything because the patient had already left the premises. Police responded to a 999 call, but a short time later Mrs Patterson was reported to have died at the railway station.
South West London & St George’s Mental Health NHS Trust (which runs Springfield Hospital) and Epsom and St Helier University Hospitals NHS Trust were both represented at the inquest as Interested Persons.
Article 2 ECHR
Whilst she was not sectioned at any time, a message had been passed to ambulance staff transferring Mrs Patterson back to St Helier that she should not be allowed to leave hospital. This meant that the inquest raised the question of whether an ‘operational duty’ to protect the deceased’s right to life under Article 2 arose.
The Court accepted that Article 2 was engaged by analogy to the Supreme Court’s 2012 judgment in Rabone.
The Court’s conclusion
After a 4-day inquest the Coroner returned a narrative conclusion. He found that there had been a “gross failure” to provide Mrs Patterson with “basic medical care”, meaning that her death was contributed to by neglect.
The Coroner criticised failures of communication between the two hospitals in relation to Mrs Patterson’s mental health status, which meant that adequate arrangements to care for her needs were not put in place.
He found the escorting HCA to have been an unreliable witness, but that she also had been given inadequate instructions. The Coroner noted that the HCA did not want to escort Mrs Patterson and that she had to be convinced to do so. “Her conduct throughout that entire evening seemed to be one of a person keen to extract themselves from that task and return to her normal place of work.”
The Coroner noted the response of the second HCA to Mrs Patterson’s first attempt to abscond and, in particular, her failure to to report the incident to a more senior colleague. He went on to note that the response by the supervising nurse to the second absconding attempt was “fundamentally undermined” by the inadequacy of the information she possessed.
The Coroner also highlighted that Mrs Patterson had been left to wait for some twelve hours on 7 November prior to her brief transfer to Springfield. In the context of Mrs Patterson’s mental health status, the Coroner considered that this might have contributed to her death.
The Trusts’ response
The Coroner was satisfied that both Trusts had made a number of efforts to address the failings. However, he asked for a consolidated report addressing the matters raised at the inquest.
Mrs Patterson was aged 64 and leaves behind a husband and two adult children.
