Media Media releases Darlington coroner writes two reports to prevent future deaths following Mina Topley-Bird inquest 19 April 2021 Mina Topley-Bird, 24, was a singer from London. She died during a mental health crisis on 8 May 2019, whilst a voluntary patient in West Park Hospital in Darlington, run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV). She was also under the care of her local mental health services, South London and Maudsley NHS Foundation Trust (SLaM), and had a history of mental ill health. The inquest into Mina’s death concluded on 1 April 2021 at Durham and Darlington Coroner’s Court, after three days of evidence before a jury. It highlighted a number of issues in the care she received, including failures in communications between the two Trusts responsible for her care as TEWV failed to obtain her medical records or appreciate her increasing risk of self-harm. Following the inquest conclusion the coroner, HM Assistant Coroner James Thompson, has now written two Reports to Prevent Future Deaths, as part of his duty to highlight ongoing concerns: One to the Secretary of State for Health regarding the lack of a national policy dealing with the transfer of patients between Trusts. Current arrangements are ad hoc and left to individual trusts to pursue as they see fit. The other to the Chief Executive of TEWV on addressing their medical records system as clinical documents cannot always be uploaded in their original form; the inability of psychiatric liaison team staff to print documents when working in A&E, reviews for ligature points, the appointment of Bed Managers across the Trust and the risk assessment and safety summary process for patients. Tees, Esk and Wear Valley Trust has faced significant criticism in recent months and years, with a high number of deaths of inpatients and patients in the community, many of whom were young women. In response to these and the inquest findings, Elizabeth Conlon, Mina’s aunt said: “It never entered our minds that those responsible for keeping Mina safe at West Park Hospital where she was admitted far from home would not have looked at her medical records detailing her previous self-harming behaviour and previous inpatient stays. It’s a terrible thing that Mina was snatched away so young with so much to offer and achieve. Mina was doing what she loved and it was so important to her to work with her friends and to produce the music she did. She wanted the opportunity to embrace life and perform despite the challenges she faced.” Elizabeth also shared the words that Mina wrote before her death: “The past 6 years have sometimes been filled with glory and light. And I have been incredibly blessed and lucky I’ve been trying to be grateful. And I have been doing my best. I’ve been trying…. and I still have to work harder on taking care of myself.” Background Three days prior to her death, Mina was on the way back from a performance with her band 404 in Newcastle on 5 May 2019. She became ill, exhibiting symptoms of psychosis and suicidal behaviour, and after presenting at A&E at Darlington Memorial Hospital she was admitted to West Park Hospital for mental ill health. Whilst Mina was in A&E, contact was made with SLaM to obtain Mina’s medical records. However, these stayed within a nurse’s inbox and were not forwarded to the staff at West Park Hospital, who had limited information about Mina’s background. During the inquest TEWV recognised there were significant gaps in their knowledge of Mina’s past hospital admissions and suicide attempts. The plan at West Park Hospital was to keep Mina stable until she could be transferred to London, to a bed in one of SLaM’s inpatient units. On 8 May 2019, Mina went to the nurses’ office on her ward to ask if there was any news about her transfer back to London. Mina was told there was still no bed yet available. Mina then made a comment to a nurse indicating that she might as well kill herself and asked to see a psychiatrist. After speaking with Mina for just three minutes, the nurse dismissed this comment as being ‘flippant’ and having been said in a ‘jovial manner’. This is despite Mina potentially indicating she had been considering the ways she could harm herself whilst in hospital. The nurse’s evidence was that Mina ended the conversation, noting she had to make a telephone call, and she went back to her bedroom. Less than an hour later, during her next scheduled check, Mina was found unconscious in her room, having used a ligature. CPR attempts were unsuccessful, and she was pronounced dead shortly afterwards. Inquest Conclusions After hearing evidence over three days the inquest jury concluded: “Information/ documentation from SLaM was not sent onto West Park Hospital, nor did they request this information from Darlington Memorial Hospital or SLaM. This lack of information sharing therefore led to West Park Hospital not having a full understanding of Mina’s mental health.” The jury further concluded: There was a failure on 8 May 2019 to appreciate that Mina was at increased risk of suicide/ self-harm following her interaction with a nurse at approximately 2.50pm; There was a failure on 8 May 2019 to take precautions against that increased risk for example via further engagement with Mina and checks on her; and The absence of Mina’s historic medical records at West Park Hospital hindered staff from appreciating the nature and extent of Mina’s impulsive behaviour and the risk of rapid deterioration. Clair Hilder of Deighton Pierce Glynn said: “All too frequently I see cases where comments made by patients about suicide or self-harm are dismissed as not having been said in the correct way to cause concern with fatal consequences. TEWV’s own Harm Minimisation policy acknowledges that the first few days following admission should be recognised as a period of high risk. Sadly, in Mina’s case no one felt the need to obtain her records, relying too heavily on her presentation, and as a result an opportunity for greater engagement and support was lost.” Jasmine Leng, Senior Caseworker at INQUEST, said: “INQUEST is extremely concerned about the high levels of preventable deaths of people under the care of Tees, Esk and Wear Valleys NHS Foundation Trust. There appears to be a pattern of failures both in inpatient and community mental healthcare in the area. This critical inquest into Mina’s premature death demonstrates some of the issues facing the Trust, and underscores the need for urgent change to protect lives.” ENDS NOTES TO EDITORS For further information please contact Lucy McKay on 020 7263 1111 or [email protected] The family is represented by INQUEST Lawyers Group members Clair Hilder of Deighton Pierce Glynn Solicitors and Alison Gerry of Doughty Street Chambers. The full reports to Prevent Future Deaths are available here. In the past four years, INQUEST is aware of at least ten deaths of inpatients under the care of Tees, Esk and Wear Valleys NHS Foundation Trust, and many more deaths of people in the community. We continue to work with families and their legal representatives to challenge this high number of deaths and push for change Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests. The inquest into Mina’s death took place Before HM Assistant Coroner James Thompson at Durham and Darlington Coroner’s Court from 29 March 2021 – 1 April 2021.