Gorleston mental health patient, who jumped to her death from Market Gates car park roof, should not have been allowed out of Great Yarmouth hospital, inquest told
08:17 05 July 2014
A mental health patient who jumped to her death from the top floor of a multi-storey car park should never have been allowed out of a secure hospital on unescorted leave, an inquest heard.
Donna Carrigan, who had a history of mental health issues and previous suicide attempts, was an inpatient at Northgate Hospital, in Great Yarmouth, when she was allowed to leave unaccompanied on the morning of August 10, 2012. Less than an hour after leaving the Norfolk and Suffolk NHS Foundation Trust-run facility, the 47-year-old jumped from the top floor of the Market Gates car park in the town.
A three-day Norwich inquest heard that Mrs Carrigan had been granted permission to visit the nearby shop at about 9am on August 10 to buy cigarettes. Although she was an informal patient, staff could have prevented her leaving using powers under the Mental Health Act.
When she did not return, staff at the mental health hospital grew concerned and reported her as missing to police. Following her fall, despite attempts to resuscitate her, she was declared dead at the scene at about 10.20am.
The inquest heard that the hospital’s multidisciplinary team had not been consulted before she was granted leave, the decision had been taken without reference to her case notes and risk assessments, and staff were not aware of her leave status.
As part of a narrative conclusion, assistant coroner for Norfolk, David Osborne said Mrs Carrigan killed herself by jumping from the car park roof. He said: “I am satisfied that Donna should not have been given unescorted leave on August 10, 2012. Furthermore, had the MDT been consulted, she would not have been allowed leave and would have been detained at the hospital, if necessary. I’m also satisfied that, had a better system of identifying Donna’s leave status been in operation, the decision would have been referred to the MDT.”
The inquest heard that the trust investigated the death and steps have since been taken to avoid such a tragedy happening again. In future, the MDT should always be consulted before granting leave to any patient, and the patients’ leave status should be recorded on a board in the office. Care plans and risk assessments must also be kept up to date. Mr Osborne said he was satisfied that steps taken so far and those about to be implemented, would help avoid the risk of a similar tragedy.
Mrs Carrigan, of St Hilda’s Crescent, Gorleston, had agreed to be voluntarily admitted to Hellesdon Hospital on July 26, 2012, and was transferred to Northgate Hospital four days later.
After the inquest, Dr Jane Sayer, the trust’s director of nursing, said: “Our thoughts, first and foremost, are with the family of Donna Carrigan. We accept there were failings in her care and we apologise to the family for those failings. We take any death in our services extremely seriously. We have carried out a thorough review and taken action to improve care planning and risk assessment for our patients as a direct result of this tragic event.”