Jury finds shortcomings, flaws and missed opportunities in care of detained patient: Leila Benyounes acts in Article 2 Inquest
Leila Benyounes represented the Family of Donna Levin in an Article 2 inquest at Teesside Coroner’s Court presided over by the Senior Coroner for Teesside and Hartlepool, Ms Clare Bailey, sitting with a jury.
Donna, who was a much loved 54-year-old mother of three and special educational needs teacher, was admitted to Roseberry Park Hospital on 28 December 2019 following increased concerns for her safety by her Family. She had been struggling with her mental health for a few months and had been diagnosed with obsessive compulsive disorder. Donna died on 8 January after being found unresponsive in her room at the hospital on 4 January 2020 whilst she was detained under the Mental Health Act.
Following a seven-day inquest during which fourteen live witnesses gave evidence, the jury found that there were shortcomings, flaws and missed opportunities in the care provided to Donna.
The jury found that key risk information was not included in a verbal handover from day staff to night staff or recorded in the electronic medical records, some of which were amended after events. These shortcomings meant that Donna’s risk levels were not amended in a risk assessment, and there was no change to the minimum hourly level of observations and engagements, which should have been increased.
After Donna asked to leave the ward to kill herself, and Donna was detained under the Mental Health Act, the jury found that there was no further assessment to take into account Donna’s further deterioration. Planned hourly checks were not undertaken, the observation sheet was falsely completed, and there were several missed opportunities in the doctor seeing Donna. Significantly, the jury found that the risk management plan and risk safety were not updated appropriately.
In concluding that Donna died by suicide due to suffering from a mental illness, the jury found that the risks of encouraging sleep to support long term treatment did not outweigh the risk of ensuring short term safety and the risks should have been further considered until the doctor saw Donna.
Links to local news articles:
Family of Stockton teacher Donna Levin release statement after inquest
Family’s ‘painful clarity after clear shortcomings’ in bubbly mum’s care at Roseberry Park Hospital
Jury retire in inquest into ‘full of joy’ teacher allegedly failed by Roseberry Park Hospital
Staff missed check on mum at Roseberry Park Hospital before tragedy
Ms Benyounes was instructed by Lois Hepworth of Watson Woodhouse Solicitors.
Leila Benyounes is Head of the Inquests Team at Parklane Plowden Chambers and is ranked by Legal 500 and Chambers and Partners for Inquests and Inquiries and Clinical Negligence. Leila is appointed as an Assistant Coroner in two coronial areas and Leila regularly represents interested persons in a wide range of inquests including Article 2 jury inquests and complex medical matters. She has a special interest in obstetric, birth injury and fatal cases providing representation at inquest and in clinical negligence claims. She has been appointed to the Attorney General Regional Civil Panel Band A since 2010. Her full profile can be accessed here.
