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Mental health unit suicide 'didn't need to happen', say daughters


The family of a woman, who was the seventh person in seven years to take her own life by the same means at units run by an NHS trust, said it "shouldn't have happened.”

Azra Hussain, 41, died at the secure accommodation at Mary Seacole House, Winson Green, in Birmingham, on May 6 2020.

An inquest concluded Ms Hussain would still be alive if not for a series of failures by a mental health trust.

Her daughters are now calling for a public inquiry after their mother's death and health and care regulator, the Care Quality Commission (CQC) has demanded Birmingham and Solihull Mental Health NHS Foundation Trust update all its doors in secure accommodation.

Ms Hussain, who experienced bipolar manic episodes, died despite being on 15-minute observations.

Ms Ul Hasan said "It's been heartbreaking. I can't comprehend, or put into words, how awful it's been. She shouldn't have died. It shouldn't have happened, it didn't need to happen. She didn't deserve all the pain, all the suffering."

Two months before her death, Ms Hussain had been due to start electroconvulsive therapy (ECT), but, due to an administrative error, the treatment was cancelled and then no longer possible because of Covid-19 restrictions.

The inquest jury concluded if she had been given this treatment, she would have been likely to have lived.

Ms Hussain's other daughter, Shammyla Bi, said they were calling for the public inquiry so other families did not have a similar experienc

She added: "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."

Although Ms Hussain had previously threatened to take an overdose, she had not shown any intention of using a ligature until two days before her death.

After she told her daughters, they then contacted staff at the unit but no-one recorded the incident and her risk of suicide was not reconsidered.

In November 2019, the trust had given the bathroom doors the highest risk score possible but Area Coroner for Birmingham and Solihull, Emma Brown, said nothing had been done to correct it, despite alarmed pressure sensors having existed for at least 10 years.

The inquest jury recognised there was a clear risk the bathroom door could be used as a ligature point and there was a foreseeable risk that Ms Hussain would attempt suicide.

The jury said that, had adequate measures been taken, it was likely her death would have been prevented.

Evidence from an internal investigation by the trust showed seven patients had died in hangings from bathroom and bedroom doors at its secure accommodation since 2013.

The coroner has requested pressure sensors be fitted to all unobserved doors in the trust's secure units.

Following Ms Hussain's death, the CQC carried out an unannounced inspection and November 2020 its report said the trust must address all ligature risks by June.

Ms Brown is also writing a Prevention of Future Deaths Regulation 28 letter believing, in the absence of national regulations, unless pressure sensors are fitted to all doors where patients cannot be seen in secure mental health units, then the risk to patients across the country will continue.