A young woman with serious mental health problems died of suicide after a series of NHS trust errors, a jury at an inquest into her death has found.
Sophie Payne, 22, died in July 2017 at the Rose ward of Queen Mary hospital in Roehampton, south-west London.
The jury highlighted how, despite the fact Payne had apparently tried to take her own life earlier that day, staff did not remove from her room an item she had used in that suicide attempt and went on to use that evening.
“[The item] not being removed from Sophie’s room was a contributing factor or cause of Sophie’s death,” the jury said in a seven-page record of the inquest at Westminster coroner’s court in central London.
The jury argued the item should also have been removed because Payne 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 episodes.
The jury said: “There were failing[s] 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 Payne’s death.
It also found that her care plan was not updated properly after the 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.
Deborah Coles, the director of the charity Inquest, which supported 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.”