Doctor admits mental health staff at Mansfield hospital failed in care of woman who took her own life

Rianna Poiana-Lazarec died on January 6, 2025, after being found unresponsive on Beech Ward, at Sherwood Oaks Hospital in Mansfield.

Her inquest, which began on June 15, was told on the first day of evidence that hourly observational checks were not increased in frequency – despite the 20-year-old having self-harmed significantly in the days prior to her death.

On June 16, the inquest, in front of a jury, heard from Dr Imad Kaddoura, a psychiatrist who was heavily involved in meetings regarding Rianna’s care after she arrived back at Sherwood Oaks, run by Nottinghamshire Healthcare NHS Foundation Trust.

The jury was told how Rianna had been a patient at the psychiatric intensive care unit (PICU) at Cygnet Hospital in Durham before she returned to Mansfield on November 7, 2024, on the Beech Ward unit.

She was detained under Section 3 of the Mental Health Act until November 28, when she was taken off Section 3 but agreed to remain at the hospital as an informal, voluntary patient, arguing that her mental health was not improving under heavy restrictions.

Clinical leaders agreed to this in a meeting, despite at least one member of staff expressing concerns about the risk considering her history of self-harm.

Rianna promised to work with staff, take medication and not abscond.

She had expressed suicidal ideation, but Dr Kaddoura told the jury that her behaviour and comments were not strange or unusual given her diagnosis with Emotionally Unstable Personality Disorder (EUPD).

By December 10, Rianna was asking to leave Beech ward and expressed frustration at what she felt was staff being ‘too busy’ to spend time with her, as well as with another patient on the ward.

She said that the patient in question had been on Fir Ward when Rianna had been stationed there in between July and October that year and had ‘attacked’ her and ‘picked on’ her during that time.

She also described the ward as chaotic and asked if there was a chance she could move to Highbury Hospital in Bulwell, also run by Nottinghamshire Healthcare, in Nottingham, the hearing was told.

Dr Kaddoura said this request was not dismissed but that the circumstances were difficult at the time to move her there.

By December 17 Rianna was intimating she was planning to leave her voluntary placement, at which point she was sectioned for six hours under Section 52 of the Mental Health Act due to staff feeling that her leaving would be unsafe.

She had expressed a desire to go home to spend Christmas with her family, but, having shown an increase in self-harm incidents, she was detained under Section 3 again on Christmas Eve, with observations every 15 minutes.

Records show that, from that date, she self-harmed every day – but on December 30, her observations were reduced from every 15 minutes to hourly.

Each time, it was with the same materials that she could find in her bedroom, the inquest was told.

She self-harmed again on January 1 and January 3, requiring oxygen to resuscitate her.

But on June 15, the inquest was told how observation frequency was not increased.

And Dr Kaddoura admitted that there was no review of the materials in Rianna’s bedroom – and said there should have been.

It was on January 4, 2025, that she was found unresponsive and was taken to King’s Mill Hospital in Sutton where she died two days later.

In a statement read to the jury, Laura Wilkinson, Rianna’s named nurse at Sherwood Oaks, said she didn’t believe Rianna had intended to take her own life.

The modern languages student had previously said that her self-harm was a way of expressing her frustration, but not a genuine attempt at suicide.

The inquest, which is set to conclude on Friday, June 19, continues.