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Woman who drowned in Norwich hospital bath died accidentally, inquest concludes

PUBLISHED: 10:21 05 March 2016 | UPDATED: 10:21 05 March 2016

Norwich coroners court

Norwich coroners court

Archant 2012

A woman with dementia who drowned in a hospital bath was found to have run a bath the day before her death.

But mental health staff at the Julian Hospital, in Bowthorpe Road, Norwich, took no formal action, and the 78-year-old repeated her actions the next day with fatal consequences.

An inquest jury concluded that Joan Darnell died accidentally, and raised concerns about factors that allowed her to enter an unlocked bathroom unobserved and run a bath. Jurors said the fact no formal action was taken after the incident the day before her death and that the door was unlocked were contributing factors. And issues with the observation system “contributed to staff not being able to provide the appropriate level of care and supervision”.

The family of Mrs Darnell, who had bipolar disorder, were too upset to speak following yesterday’s inquest.

The widow, of Field Grange, Lowestoft was sectioned in September 2014 and died on October 16, 2014. On admission to the hospital she was put on observations four times per hour, later upped to six times per hour.

Staff reported that she would pace up and down corridors, get into altercations and that her “intrusive” behaviour made her vulnerable.

However her observations were reduced to an hourly head count the day before she died.

A post-mortem examination report found that Mrs Darnell had bruising consistent with a fall into the bath and an impact to her head which suggested this was accidental.

She also had underlying heart disease, though no evidence was given as to what caused her to fall into the bath.

Senior coroner Jacqueline Lake, in summing up, said there was no written policy on locking bathroom doors, but many witnesses at the hearing had given evidence that there was an expectation doors should be locked.

She ordered no reports for the prevention of future deaths following the incident at the hospital, run by Norfolk and Suffolk NHS Foundation Trust.

It happened on the hospital’s Blickling Ward, where there are around 15 elderly patients with memory problems.

Speaking on the first day of the three-day inquest, Dr Ibanibo Braide had said staff tried not to escalate observations where possible.

“We try to make patients as comfortable as possible in spite of the challenging nature of their presentation,” he said.

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