A mental health unit has been slammed after failing to supervise a sick woman who left its care and twice headed for King’s Mill Reservoir - before being found dead floating face down by her daughter.
Carol Vaughan (61) had been a voluntary patient at Millbrook psychiatric unit on the Mansfield/Sutton border - but was able to leave unnoticed.
The mother-of-three was then found in the freezing water of the reservoir.
An inquest into her death this week at Nottingham Coroner’s Court was told that it was the second time she had left Millbrook unnoticed in little over a month and headed for the reservoir.
On the first occasion, 2nd December 2013, she was rescued from the water by a passer-by.
At the time her family raised serious concerns about her safety and lack of supervision.
Despite being under 15-minute observations, she left the premises again on the morning of 14th January last year for a cigarette break but did not return.
Staff failed to notice that she had even left the ward.
Giving her conclusions this week, Nottinghamshire coroner Mairin Casey returned a narrative verdict and found that those responsible for Mrs Vaughan’s care at the Millbrook unit failed to supervise her properly, failed to appreciate the family’s concerns or views in relation to her care, and failed to liaise with professionals in the community such as social workers and the community psychiatric nurses.
She described the failings as ‘worrying’ and indicated that she would be sharing her findings with coroners across the country, hoping that these failings would not be seen elsewhere.
Mrs Vaughan, who was from the Newark area, had a history of mental health problems, suffering from bi-polar disorder.
Her mental heath deteriorated in September 2013, experiencing episodes of violent behaviour, and on a number of occasions, self-harmed.
On 30th November 2013, she was found on a dual carriageway near to the unit.
The inquest was told how Mrs Vaughan had recently finished a period of detention under the mental health act before she went to Millbrook voluntarily.
In a statement, Nottinghamshire Healthcare NHS Trust - which oversees Millbrook - offered ‘sincere condolences to the family and friends’.
It added: “The trust has undertaken a thorough internal investigation to review the care and support provided to Mrs Vaughan.
“A comprehensive action plan was developed following the investigation; the actions were taken very seriously and there have been significant changes made as a result.
“This will be of small comfort to Mrs Vaughan’s family but will improve services for the future. We welcome the further recommendations by the coroner in relation to gaps identified in the care and treatment provided to Mrs Vaughan for which we apologise.”
Meanwhile, Mrs Vaughan’s family representative, Julie Hardy, of Barratt, Goff and Tomlinson Solicitors said: “The family is pleased that the coroner has carried out such a thorough investigation in relation to the care that Carol received prior to her death, and that she has identified the failings which have concerned the family over the last year.
“Nothing can bring Carol back, or take away Karen’s last memories of her mother. The family hope however that the hospital trust will take on board the coroner’s findings and recommendations to ensure that other patients are safe in their care.
“Carol’s family accepts that they were enormous pressures on the doctors, nurses and carers at the Millbrook unit, and patient safety was compromised because of these pressures.
“They feel that further resources should be made available for the care of psychiatric patients. It is their hope that changes can be made, not just at Millbrook but throughout mental health services, to prevent the failings which were highlighted in the evidence given at the inquest.”