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Mental health trust missed multiple opportunities to prevent woman's death


A health trust was criticized after a woman became the seventh person in seven years to take her own life in the same way at one of its hospitals.

Azra Hussain, 41, died at Mary Seacole House, a mental health hospital run by Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHT) on 6 May 2020 after several missed opportunities to prevent this happening.

Ms Hussain had a history of bipolar affective disorder (BAD) and was sectioned under the Mental Health Act 1983 and admitted to Mary Seacole House suffering from mania caused by her illness on 26 December 2019.  Following admission, her manic episode gave way to severe depression.

She was taken for electroconvulsive therapy (ECT) On 24 March 2020 to treat her depression and suicidal thoughts but an administrative error meant that the treatment was not able to commence.

As Azra Hussain’s mental health deteriorated, her risk increased and, on 4 May 2020, she changed from talking about killing herself to attempting to do so by trying to tie a ligature with shoelaces.

Staff on duty failed to respond adequately, or properly document, the incident or raise an incident report, and so her risk assessment was not updated, and other hospital staff, including her doctors, were not told about her suicide attempt.

In total, there were four missed opportunities to act upon or pass the information on.   The level of staff observations for Azra Hussain’s  were not increased and other objects that she could potentially use as ligatures were not removed from her room.

As a result Azra Hussain used a bedsheet to hang herself from the en-suite bathroom door in her room on 6 May 2020 and was later found by staff on a routine check.

Azra’s family had been excluded from remotely participating in a multidisciplinary team meeting (MDT) hours before her death which an inquest into her death heard was another missed opportunity for discussions about her safety.

At an inquest at Birmingham and Solihull Coroner’s Court heard that Azra Hussain was the seventh patient of the Trust to use an en-suite bathroom door to hang themselves since 2013 but, in spite of this, door pressure sensors, which were easily available, had not been installed by the Trust.

The jury concluded that three failings led to Azra Hussain’s death. These were the missed opportunity to start ECT treatment that could have prevented her death; not foreseeing that she may commit suicide and failing to introduce measures to prevent her doing so.

HM Area Coroner, Emma Brown, noted that while BSMHT was going to install pressure sensors on en-suite bathroom doors at Mary Seacole House, there was a lack of national regulation or guidance on the risk presented by internal doors in patients’ bedrooms.

The coroner issued a Regulation 28, ‘Prevention of Future Deaths’ Report requesting that BSMHT, the Clinical Commissioning Group (CCG) for Birmingham and Solihull, Care Quality Commission (CQC) and the Health & Safety Executive (HSE)  act to remedy the persisting risk posed by the lack of sensor alarms in areas where patients spend time, unobserved, in mental health units operated by Trusts and private providers around the country.

A second condition requests BSMHT to ensure ensures that families can attend MDT meetings, using a remote platform or by telephone.

Following Azra Hussain’s death, the Care Quality Commission (CQC) conducted an unannounced inspection of BSMHT On 23 November 2020, including Ward 2 of Mary Seacole House, where she was a patient. 

Following an inspection, the CQC put conditions on BSMHT’s registration, requiring the Trust to implement an effective system to improve risk assessments and care planning by 5 February 2021 and to address all ligature risks by 18 June 2021.

The CQC’s head of hospital inspection (mental health and community health services), Jenny Wilkes, said: We have imposed urgent conditions on the Trust’s registration as a result of our concerns about ligature risks, care planning and risk assessments. We took this urgent action to ensure that people using the services are not exposed to any risk of harm.”

One of Azra Hussain’s two daughters, Shammyla Bi, said they are calling for a public inquiry so other families do not have a similar experience.

She said: "As a family we don't want to hear that this has happened again, we want people to go into a place of care... and not have to worry about them never coming out again."