Staff Downgraded Level Of Observation From Constant To ‘Minimal’ Just Days After Failed Suicide Attempt

A devoted mum who choked to death on tissues at a mental health facility had staff observations of her downgraded to ‘minimal’ just days after a previous suicide attempt, an inquest has heard.

Melanie Lowe, 41, from Tiptree, Essex was found unresponsive at the Derwent Centre in Harlow on March 2, 2016.

A three-day jury inquest at Chelmsford Coroner’s Court, which concluded on November 9 last year, heard that the mother-of-two was found unconscious in her room and rushed to hospital, but was pronounced dead later that evening.

Her devastated family instructed expert medical negligence lawyers at Irwin Mitchell to investigate Melanie’s care under North Essex Partnership University NHS Trust following her admission to the Derwent Centre on February 23, and specifically the decision to downgrade monitoring of her.

Melanie’s partner, Tony, said: “We entrusted the Derwent Centre with Melanie’s care. We thought she would be protected and that she was in the best place to make a recovery.

“Nothing can change what has happened to Melanie or to our family. But all we can hope for now is that lessons are learned so that no one else suffers the loss we feel every day.”

The inquest heard that Melanie, who had a history of mental illness, had previously taken an overdose of tablets from her wash bag while at the centre. The bag was supposed to be thoroughly searched on admission.

While in hospital recovering she was under constant observation. But when she was re-admitted to the Derwent Centre she was reassessed by a locum psychiatrist who downgraded her observation requirement from constant ‘eyes-on’ to minimal, meaning she was only checked every hour.

Coroner Caroline Beasley-Murray said the risk to Melanie was not managed within the Trust’s own policy and that that the locum psychiatrist was unaware of it altogether.

Melanie’s medical cause of death was recorded as hypoxic brain injury and airway obstruction, with the jury adding that her risk of self-harm and suicide was not adequately assessed and reviewed and that adequate precautions were not taken to manage her risk of self-harm or suicide.

Melanie was reportedly seen at 7.30am on the morning of her death, before being discovered at 7.35am. However the inquest heard there are no observation notes from that time.

Expert Opinion

“Melanie was a devoted mother to her two children and her family are still reeling from her death.

“The inquest identified a number of failings which were incredibly distressing for Melanie’s family who now know that more could have been done to prevent her death.

“While nothing can change what has happened to Melanie, it is now her family’s greatest wish that lessons are learned from this tragedy to protect other vulnerable people in mental health crisis.

“We are examining the inquest’s findings and advising the family as to the next steps available to them.
Rachel Codd - Solicitor

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