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Major errors at NHS Trust contributed to death.

A young woman with mental health problems killed herself after a series of major errors by the NHS trust that was looking after her, an inquest jury found.

The jury issued a scathing assessment of the care received by Sophie Payne, 22, a “warm, bright and creative” woman who died in July 2017 in the Rose Ward, Queen Mary Hospital, Roehampton, south-west London.

The jury found that five key mistakes by staff in the mental health unit contributed to the death of Sophie Payne, who was found unresponsive at 8.45pm on 27 July 2017..

The jury highlighted how, despite Sophie Payne apparently trying to take her own life earlier that day, staff did not remove an item from her room which she had used in that suicide attempt and went on to kill herself with that evening.

In a seven-page record of the inquest at Westminster coroner’s court, the jury said: “The item not being removed from Sophie’s room was a contributing factor, or cause, of Sophie’s death.”

The jury argued that the item should also have been removed because the young woman had used it in four previous apparent suicide attempts during her 24 days in the unit. Staff did not file an incident report about any of those four attempts, despite their seriousness and Ms Payne’s persistent attempts to harm herself.

The jury added: “There were failings in incident reporting which contributed to Sophie’s death. There were four incidents in which the item was found in Sophie’s mouth. No incident report was generated.

“The item in her mouth posed a ‘significant risk’, yet on four occasions was not reported to risk assessment.”

The jury said this led to a failure in risk assessment that separately contributed to Sophie Payne’s death.

It also found that her care plan, a document spelling out her treatment, was not updated properly after the apparent suicide attempts, a breach of the guidelines drawn up by the South West London and St George’s mental health NHS trust (SWLSTG), which runs the hospital.

The jury said the trust’s failure to hold a multi-professional review meeting after Payne’s persistent self-harm was the fifth mistake that contributed to her death.

Ms Payne, a former youth worker who planned to go to university, suffered from post-traumatic stress disorder, bipolar disorder and emotionally unstable personality disorder. She had first been treated for mental health problems as a teenager after being sexually assaulted.

Her father, Mike Payne, accused Rose ward staff of being “complacent” in their care and not learning from his daughter’s first apparent suicide on the day she died.

He said: “In her last four years she spent many periods in and out of different acute psychiatric wards. In our experience the level of care she received during her final admission on Rose ward was by far the most inadequate.

“Her care plan was non-existent. Fewer than 10% of self-harm incidents were reported and her overall care smacked of complacency.”

Director of the charity Inquest, Deborah Coles, which supported Sophie Payne’s family, said: “We are increasingly concerned about the repeated patterns of failure of vulnerable women like Sophie in secure mental health care. All the warning signs were there but yet again she was failed by the very systems that were meant to keep her safe.”

A SWLSTG spokesperson said the Trust fully accepted the findings by the coroner and jury and that it had started implementing recommendations made by an independent investigation into Ms Payne’s death led by an outside consultant psychiatrist.

The spokesperson added: “During the last 11 months we have made significant improvements in a number of areas including in the quality and consistency of incident reporting, the process of escalating concerns, greater integration of risk assessments and care planning.”