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Medics 'did not fully consider risk to mum's life', inquest told.


Mental health teams who did not fully consider a patient's risk to their own life "possibly contributed" to her death, an inquest heard.

Sarah Moore, 27, from Derby, was found dead less than 24 hours after a planned discharge on 20 February 2018.

She repeatedly told medics she wanted to take her own life in Allestree Park if released from the Radbourne Unit mental health ward, the inquest heard.

Derby Coroner's Court heard Ms Moore had attended A&E in the city on 31 December 2017 after posting on parents’ online forum, Netmums, she had "thoughts of suicide." She was persuaded to seek help by one of the website's administrators, the court heard.

Ms Moore was transferred to a crisis house, but staff said they could not meet her needs. She was then admitted to the Radbourne Unit, Littleover, and assessed as a "moderate to high risk" of self harm.

Derbyshire area coroner, Peter Nieto, said Sarah Moore told medics she did not want information about her treatment or care plans to be disclosed to her parents,

Throughout her admission, Ms Moore expressed thoughts of self-harm and stated she would take her own life if discharged, the inquest heard.

On 6 February, about two weeks before her death, Ms Moore absconded from the ward saying she intended to take her own life but was persuaded to return by staff and was placed under an emergency section of the mental health act pending a full assessment, the hearing was told.

The inquest heard medics "reached a consensus" that further admission "would not be helpful" to Sarah and her best course was to be sent home for treatment in the community.

Some staff members did express concerns around self-harm and a day before the planned discharge date, Ms Moore again expressed her wish to take her own life to a nurse, the coroner was told.

This same nurse expressed concerns around Ms Moore's discharge but was told by another colleague it was "the right course" and any self-harm was "unlikely to be serious."

The court heard a discharge form was pre-signed six days before Ms Moore was due to be sent home which the coroner said, "should not happen."

Ms Moore fled the building about 25 minutes before her discharge time and, although staff went after her, they were advised they "had no power" to keep her on the ward.

There were discussions on whether to inform her parents, but staff were told she had "not consented" to this.

The court heard Ms Moore went to Allestree Park and again posted on Netmums sharing her location, saying she was going to take her own life. The website administrator contacted her local force of Kent Police before they alerted officers in Derbyshire. Ms Moore was found early the next morning.

Coroner, Peter Nieto returned a narrative verdict and, in his conclusion, said: "Sarah died but it is not clear whether she intended to take her own life because she sent messages stating what she intended to do and where she was, implying she wanted to be found and assisted.

"Sarah's death was possibly contributed to by a multi-disciplinary mental health team not fully considering information containing her risk, particularly in relation to her discharge and not exploring that risk with her."

Derbyshire Healthcare NHS Foundation Trust said it will take the coroner's recommendations on board "to ensure ongoing improvements are made to the services we provide.”

The trust’s medical director, Arun Chidambaram, said: "We are sorry there were gaps in the care we provided, and we are committed to learning and improving our services.

"We have co-operated with the inquest to fully understand the circumstances regarding Sarah's sad death, building on the changes we have made through our own internal investigation."