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Hellesdon Hospital failings increased likelihood of mother-of-two’s death, inquest told

Clare Henderson

Clare Henderson

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Failings in the treatment of a patient at Hellesdon Hospital who was later found drowned increased the likelihood of her death, an inquest in Norwich heard.

Mother-of-two Clare Henderson, 42, was found drowned at the Broad at Rockland St Mary, near Norwich, on July 22 last year.

She was an informal patient at the hospital and had been allowed out unescorted at about 9am the previous day on day leave, but on condition that she returned at 7pm. She was seen in Rockland St Mary at about 2pm that day by housing manager Belinda Wicks who described her as being “in an extremely anxious state”.

Miss Wicks twice rang Hellesdon with her concerns and told staff that Ms Henderson had no intention of returning, and would therefore not be back at 7pm, but no action was taken by the hospital to trace her.

Under the hospital’s protocol the police and next of kin should also have been informed that she was missing seven hours after she had failed to return on time, which would have been 2am the next day, but this was not done.

Yesterday’s inquest heard that Ms Henderson was seen in Rockland St Mary at about 6.50am on July 22 walking towards the Broad. Her body was found at about 8.30am by a fisherman. The cause of death was given as drowning.

Norfolk coroner William Armstrong, pictured, said: “The evidence has revealed failings in the way Clare was cared for by the mental health services. There was a failure to involve the family as much as appropriate.

“It’s also a major concern that information supplied by Belinda Wicks was not acted upon and a grave concern that no action was taken to trace her after she failed to return to hospital on time. This should have been done.”

Recording a narrative verdict, he said: “The fact that no action was taken with a view to tracing her following her failure to return to hospital on time increased the likelihood of her death.”

He said that she had entered the water with the intention of taking her own life, while suffering from a mental disorder.

Afterwards, Ms Henderson’s family issued a statement. It said: “We strongly feel Hellesdon failed Clare in their care and they were responsible for her being allowed to leave hospital even though we repeatedly told them she was not well enough to be allowed to leave her supposedly safe environment.

“Not only did they allow her to leave unaccompanied, but they did not inform her loved ones that they had made this decision. They also did not inform anyone when she did not return that evening as expected and we strongly believe that if they had done either of those things, Clare would not have been left in the vulnerable situation she was, enabling her to take her own life.”

The court heard that the Norfolk and Suffolk NHS Foundation Trust, which runs Hellesdon Hospital, has since made changes to the way it handles patients on day leave. In future, as soon as a patient fails to return to hospital on time, they will immediately inform the police and next of kin.

The inquest was told that Ms Henderson, whose maiden name was Ahlquist, started having mental health problems when she split up with her husband about seven years ago. She subsequently became estranged from her two sons, which added to her problems. She had been diagnosed with psychosis and schizophrenia, but she was still able to return to work as a nurse two years before her death.

In March 2011 she had been admitted to Hellesdon at her own request and was later detained at the hospital under the Mental Health Act. But her condition improved and the sectioning under the act was rescinded. She agreed, however, to remain at the hospital as an informal patient. She was allowed day leave, which was at first escorted, but leading to being unescorted.

The inquest was attended by her two sisters, Katherine Carter and Bernadette Pitt, and partner Ian Henderson. The family said during the inquest that she was a vibrant young woman, mother, daughter and sister, and had spent her whole life caring for others.

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