Azra Parveen Hussain was allegedly the seventh in-patient in seven years to die by the same means while in the care of Birmingham and Solihull Mental HealthNHS Foundation Trust (BSMHT).
A 40-year-old mother of four took her own life at an NHS mental health unit after multiple opportunities were missed to keep her safe, an inquest has found, prompting her family to call for a public inquiry.
Despite this, an inquest at Birmingham and Solihull Coroner’s Court last week heard that the Trust had not installed door pressure sensor alarms, which could have potentially alerted staff to the fatal danger these patients faced.
While BSMHT is now taking action to install pressure sensors at Mary Seacole House, where Hussain died on 6 May, Coroner Emma Brown noted a lack of national regulation or guidance on the risks presented by internal doors in patients’ bedrooms and is issuing a Prevention of Future Deaths report calling for this to be remedied across the country.
Laywers for Hussain’s family alleged that both the inquest and a recent report by England’s independent healthcare regulator, the Care Quality Commission (CQC), “expose several deeply troubling failings that led to her tragic, avoidable death”.
The inquest, which concluded on Monday, heard of a series of failings at Mary Seacole House in Hussain’s case, without some of which the jury concluded she may still be alive.
What happened during Hussain’s time in hospital?
After being sectioned in December 2019 as a result of mania caused by bipolar affective disorder, Hussain became severely depressed.
She was due to receive electroconvulsive therapy (ECT) in March to treat her depression, but an administrative error meant this did not take place – which the jury concluded could have prevented her death.
On 4 May 2020, Hussain told her family that she had attempted to take her own life, using the same method by which she died two days later. They alerted the nurse in charge who found no evidence of the attempt, which Hussain denied to them, and she was deemed not to be an immediate risk. While BSMHT later accepted this development was “significant”, the staff on duty did not document the family’s concerns or raise an incident report.
Furthermore, Hussain’s risk assessment was not updated, and other hospital staff, including her doctors, were not informed – allegedly with four missed opportunities in total to pass the information on. There was no increase in the level of observations for Hussain, which were reportedly every 15 minutes, and other objects that she could potentially use as ligatures were not removed from her room, the inquest heard.
And just hours before Hussain’s death, her family was excluded from a multidisciplinary meeting, during which they could have raised concerns about her safety, their lawyers said.
What action is being taken?
In her report, the coroner called on BSMHT to ensure that from now on families can attend multidisciplinary team meetings, using a remote platform or by telephone – in addition to a call for action to remedy the risk posed by the lack of sensor alarms in in mental health units across the country.
Meanwhile, the CQC had previously called on BSMHT – which said it accepts the inquest’s findings in full – to address all ligature risks by June.
