Mansfield: ‘No warning signs’ on day of woman’s death on hospital mental health ward
Staff involved in the care of a woman who died on a mental health ward have defended their actions.
Rianna Poiana-Lazarec died on January 6, 2025, after being found unresponsive in her bedroom at Sherwood Oaks Hospital in Mansfield two days prior.
Her inquest, taking place in front of a jury at Nottingham Coroner’s Court, heard evidence on June 18, from staff members Helen Newton, Abigail Drumm and Robert Sullivan, who all worked at the Nottinghamshire Healthcare NHS Trust-run facility in the months leading up to Ms Poiana-Lazarec’s passing.
Healthcare assistant Ms Newton, who gave evidence via a statement read to the court, was responsible for giving 20-year-old Rianna the items that she used to render herself unconscious on January 4.
University of Nottingham student Rianna, who had been known to mental health services since she was 18 and had been diagnosed with Emotionally Unstable Personality Disorder (EUPD), had used that same item to harm herself on previous days.
Explaining her decision to give Rianna the item, which was used for personal hygiene purposes, Ms Newton said in her statement: “Rianna gave me no cause for any concern, her behaviour not being anything extraordinary.”
On the day of her death, Rianna had taken a period of leave, was described as ‘bright in mood’ by Ms Newton, and was observed sitting calmly at a table in a communal area for a period of time with a pen and paper not long before the fatal incident.
She was writing down a list of make-up items, some of which had been given to her as Christmas presents by her mother and were quite expensive, that had been lost by staff.
The inquest, before coroner Simon Burge, heard that employees had to spend time watching CCTV footage to work out where the makeup had been placed.
Separately, the inquest heard that Rianna had used the item, which she later used to harm herself, for its intended purpose a few hours earlier, but that there was no set practice on the ward for the returning of such items, nor was it officially recorded when they were provided.
Abigail Drumm was the manager on Beech Ward, where Rianna was, in the months before her death, and gave evidence in person on June 18.
Questioning her on behalf of Rianna’s family, barrister Carl Buckley pointed out that records showed that on multiple occasions after incidents of self-harm, Rianna’s risk assessments were not reviewed or updated.
He also asked Ms Drumm why Rianna kept being provided with the means to harm herself in the same way that she had been doing on a daily basis in the weeks before.
Ms Drumm argued that the item was an ‘everyday object’, to which Mr Buckley suggested that every item used for self-harm is an everyday object and that no item is designed for self-harm.
In response, Ms Drumm said that staff completed ‘dynamic risk assessments’ when patients requested items, and suggested that if access to one type of item was restricted, there were other items that Rianna may have attempted to self-harm with.
She explained that restrictions can make patients feel worse, and subsequently might lead to them harming themselves more.
But she accepted ‘there are things we could have done’.
Ms Drumm also admitted that there was ‘minimal evidence’ to show what decisions were made or considered in relation to the future use of and access to the item that Rianna consistently used to harm herself.
She said: “I didn’t have any concerns with the short-term response and reactions to (Rianna’s) incidents (of self-harm) and what was done, but more so the longer-term care plan for Rianna.
“We spoke about observations quite a lot.
"What I think should have been done in Rianna’s case is looking at items used (for self-harm) and monitoring around that.
“I don’t think restricting her access to them, or observing her using them, would have been proportionate, (but) the decision I’d make would be to take it away as soon as she’d finished (using it for its intended purpose).”
Throughout the inquest, questions have been raised over why Rianna was being observed hourly before her death rather than every 15 or 30 minutes.
Ms Drumm said decisions to change patients’ observations are made on a case-by-case basis and that increasing their observations might not always be the best option for them, for example, because the more restrictive nature of an increased level of care potentially causes more distress (and leads to more self-harm).
That is despite the inquest hearing at the beginning of the day, during Ms Newton’s evidence, that hourly observations are intended for patients presenting as ‘no significant risk’.
Rianna had been found with material tied around her neck 23 times in the 23 days leading up to her death, but had been moved back from 15-minute observations to hourly observations on December 27.
Clinical team leader Robert Sullivan, who was a staff nurse on the ward at the time of Rianna’s death, had worked on her safety and care plans in the weeks before.
These plans included details about warning signs she might exhibit if she was in distress and might be more likely to self-harm.
When questioned by barrister Samantha Paxman on behalf of Nottinghamshire Healthcare, Mr Sullivan said that on January 4, 2025, Rianna was displaying none of the warning signs described.
The inquest, in which the 11-person jury is being asked to consider whether Rianna intended to take her own life and whether she may not have died if hospital practices were different, is set to conclude today (Friday).