7th July 2014

On 10 August 2012, Donna Carrigan was allowed out of Northgate Hospital, part of Norfolk and Suffolk NHS Foundation Trust, on unescorted leave and later died in Great Yarmouth. Donna was allowed to leave even though it had been decided that she should not be allowed out of the hospital due to the risk of self harm and suicide. She had told staff the day before that she was hearing voices telling her to harm herself which she was finding hard to ignore. Donna had been a patient of the Trust for over 16 years and the risks of suicide and self-harm were well known by staff.

The inquest opened on 2 July 2014 before HM Assistant Coroner David Osborne sitting at Norfolk Coroner’s Court and has heard two days of evidence followed by legal submissions. The family heard evidence that:

1. Donna should not have been allowed unescorted leave on 10 August 2012.
2. There were serious failures which led to her being allowed out.
3. The risks of self harm or suicide if allowed out were serious and were known by the staff.
4. There was a failure within the team to properly record or communicate information about Donna's risk and that she should not be allowed off the ward.
5. The risk assessment documentation was inadequately completed
6. There was a failure to ensure that Donna had a keyworker, who should have made sure Donna's care plan and risk assessment records were up to date
7. The Trust’s systems were inadequate, in particular: 
8. The system for ensuring someone carries out the role of keyworker;
9. The system on leave for informal patients, including as to how staff would be informed about the decision about leave.

The Coroner gave his conclusion on the afternoon of 4 July 2014 finding that Donna should not have been given unescorted leave and that there were other failings including a failure to update case notes and risk assessment documents, and a failure to communicate Donna’s leave status. The Coroner also agreed that Donna’s right to life under the European Convention on Human Rights was a live issue in the case.

Kenneth Carrigan, commented:

“My wife Donna Carrigan died at the age of 47 years old. She was an amazing person, I loved her very much and she was a great mum. She had been asking for help and support for mental health issues since she was 31 years old. I think she was let down by the system that failed her for 16 years. I do believe this is happening far, far too often. Its about time the public should be made aware of the lack of care for mental health patients. Donna’s death was unexpected and my children and I believe it could have been avoided if she had been given the care she needed. I am pleased that the Coroner has found that Donna should not have been let out of Hospital on that day. I supported her through all these years, and through the latter part of her life with help from our children. It has been very hard to come to terms with Donna’s death and our two children feel that they have lost their mum unnecessarily. Donna came across individuals who tried their hardest to help her, but I think in the end Donna was seriously let down by the system and her death could have been prevented.” 

Sara Lomri, solicitor for the family commented:

“It is so tragic to see the same errors repeated at Northgate Hospital, with the same devastating consequences. I represented the family of Louise Noon whose death in July 2010, two years before Donna’s death, was contributed to by a catalogue of systemic and individual failings within the same Hospital as in Donna’s care. The failings in Louise’s death included a key failure to communicate the risk of self harm within the team. In the inquest into Donna’s death we have similarly heard from Trust staff that the systems in place for recording and passing on key information regarding risk are seriously lacking, and that Donna’s risk were not properly communicated to all staff members. After Louise’s death the Coroner wrote to the Trust (copied to the Care Quality Commission), asking them to undertake a wholesale review of their systems, training and policies to protect the lives of other patients in the future. The Trust responded in July 2011 assuring the Coroner that they had undertaken this review and provided new policies and some training. It is Mr Carrigan’s position that the changes implemented as a result of Louise’s death have either not been effective or not gone far enough.”

Deborah Coles, co-director of INQUEST commented:

“This inquest finding shows once again how important it is too have a more robust mechanism for auditing actions taken in response to a death.  To have two deaths in the same hospital within two years from each other with similar systemic and individual failings is not acceptable.   Empty promises that ‘lessons will be learnt’ are not enough when we see the same failings repeat themselves with depressing regularity.”

INQUEST has been working with the family of Donna Carrigan since her death. The family is represented by INQUEST Lawyers Group members Sara Lomri from Bindmans Solicitors and barrister Adam Straw from Doughty Street chambers.