Hospital patient took life amid 'unchecked' medical records, coroner says

An NHS hospital patient took her own life with tubing stolen from medical trolley,  a coroner said.

Emma Sanders, 34, who had a history of mental illness, was being cared for in a corridor due to overcrowding at Royal Bournemouth Hospital in March 2023.

She had been brought to the hospital's emergency department on 14 March after taking an overdose, the inquest heard.

Ms Saunders was placed in a hospital corridor staffed by ambulance paramedics due to "capacity pressures”  and was found collapsed in a toilet and died from the effects of asphyxiation five days later.

Senior Dorset Coroner, Rachael Griffin, said in a Prevention of Future deaths (PFD) report that the patient might have been managed differently if health workers had checked her previous records which showed a history of self-harm and personality disorders but were not seen during her time in hospital.

Ms Griffin said that the patients’ medical records were not immediately available when she was triaged and no-one else from the hospital saw her before the fatal incident.

She said NHS Dorset and NHS England could act to prevent future deaths by addressing issues within the patient records system.

In her PFD the coroner wrote: "At 18.58 hours, when for a very short period of time there were no staff in the corridor, Emma can be seen on the corridor CCTV to secrete upon her person a nasal cannula with plastic tubing from an equipment trolley.

"At 19.53 hours Emma went to the toilet in the Emergency Department. At 20.03 hours, Emma was found in a collapsed and unresponsive condition on the floor of the toilet."

In a narrative conclusion, Ms Griffin said it was not clear whether Ms Sanders had intended to take her own life.

NHS Dorset said it would respond to the coroner in due course.