Mum, 48, was able to kill herself on NHS ward after ‘grave error’ by staff
Staff on a mental health ward where a mum-of-two ended her life still have no idea how she obtained the ligature she used to kill herself, an inquest has heard.
Michelle Sparman, 48, from Battersea in southwest London, died four days after making the attempt on her own life at Queen Mary’s Hospital in Roehampton.
The personal trainer and part-time Met Police call dispatcher was rushed to A&E at Chelsea and Westminster Hospital following an overdose on August 21, 2021.
She was then admitted voluntarily to the female-only Rose Ward at Queen Mary’s.
An inquest into her death at Inner West London Coroners’ Court was told yesterday that all new patients are categorised ‘red’ for their first 72 hours while staff get to know them.
During that time, they are supposed to be searched for any items capable of harming themselves or others, and subject to observation four times an hour.
But on August 24, Michelle was found on the floor of her bathroom with a ligature around her neck.
The inquest heard from medical staff on Rose Ward during Michelle’s admission.
Psychiatrist Dr Rose Mbah-Maduabueke told Assistant Coroner Bernard Richmond KC she believed there was a blanket ban on such items coming onto the ward.
She said patients would be searched in an airlock before entering the ward, which was open but had a locked door, with any prohibited belongings either confiscated or returned to family members.
But nurse Catherine Mhlanga suggested such items may be permitted subject to an individual risk assessment.
Mr Richmond quizzed the nurse about how they were tracked on the ward, saying staff ‘would want to make sure they know exactly where those items are’, adding: ‘If it gets into the wrong hands that would be disastrous, wouldn’t it?’
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He went on: ‘Michelle is not allowed this item, and she has used it to kill herself. She didn’t have access to this item because she was not allowed it.
‘You didn’t allow them to just come randomly on to the ward. Therefore, the question is whose [ligature] has she used to kill herself?’
Ms Mhlanga replied: ‘I can’t answer that.’
Mr Richmond suggested staff could have gone to each patient allowed to have one and asked whether they still had it, adding: ‘Did you do that?’
The nurse answered: ‘No.’
Amid confusion over what items were allowed on the ward, Mr Richmond called ward manager Meredith Kuleshnyk to give evidence.
She confirmed patients would be searched and allowed to keep certain items if it was deemed safe for them to do so in their individual risk assessment.
A note would be made to that effect but there was no centralised place where the information was stored, the inquest heard.
Ms Kuleshnyk told the inquest that ‘to [her] knowledge there was nobody on the ward’ with the item during Michelle’s admission.
The assistant coroner said it ‘hasn’t just manifested itself without somebody bringing it in’ adding: ‘Somebody hasn’t done their job properly potentially?’
Ms Kuleshnyk said there are ‘different levels of searches’ on the ward and conceded the ligature could have been missed if Michelle was wearing a ‘big baggy jumper’, adding that ‘if someone wants to hide something it’s possible in any environment, even a prison’.
The coroner went on: ‘You have got a ward you are in charge of where somebody has killed themselves and you can’t say how on earth it’s happened.
‘Aren’t you metaphorically climbing the ceiling trying to work out how this has happened?
‘Just having a word with staff isn’t going to cut it is it, there needs to be an investigation. There is a possibility here that somebody has committed a very grave error.’
Ms Kuleshnyk said: ‘We explored it, but we didn’t hit an outcome. We didn’t get any answers.’
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She told the inquest it was ‘unlikely’ there was a ligature on the ward she did not know about, adding: ‘We have very robust search procedures.’
Mr Richmond hit back: ‘Forgive me, but as far as Michelle Sparman is concerned, your search procedures could not have been less robust, could they?’
Ms Kuleshnyk told the inquest that the ‘tragic incident’ had led to ‘learning’ and changes in procedure, adding: ‘It is something I am very vigilant about.’
Jennifer MacLeod, the lawyer representing Michelle’s family, indicated they would discuss the possibility of making submissions seeking a finding of neglect when Mr Richmond delivers his conclusion later this week.
The inquest continues.
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