Islington woman's suicide was 'preventable'
PUBLISHED: 14:33 13 May 2015 | UPDATED: 14:33 13 May 2015
Coroner slams 'breakdown in communication' in health services
A shocking lapse in care led to a distraught and suicidal woman being discharged from hospital and left to throw herself off a six-storey building less than an hour later, an inquest has revealed.
Finnulla Martin, 35, found herself subject to a shambolic series of blunders by those entrusted with her wellbeing after being admitted to the Whittington Hospital.
The full and disturbing details of her death, in November last year, came to light only last week when a coroner ruled her suicide “preventable” and slammed local health services Whittington Health and Camden and Islington NHS Trust (C&I) for their failures.
St Pancras Coroner’s Court heard how Ms Martin, a beloved daughter, sister and aunt, arrived at the home of her mother on the night of November 15 after hearing voices telling her to stab her mum and jump off her balcony.
A paranoid schizophrenic, her state of mind led her devoted mother to call 999 and plead for help in caring for her.
Taken by police to the Whittington in Magdala Avenue, Archway, for assessment, it was here, her concerned family believed, Ms Martin would be safest.
But a breakdown in communication at the hospital saw their concerns ignored, incomplete medical notes scribbled on scraps of paper, and basic mental health assessments not carried out.
Despite the officers who brought her in repeating three times that she was suicidal and had threatened others, nurses left Ms Martin to wait alone in A&E for an hour-and-a-half. When she was finally seen by a psychiatry team, the officers’ messages were not forwarded and family members’ calls went unactioned.
As a result, Ms Martin was discharged with no treatment. Within an hour, she had walked back to her flat in the Bemerton estate off Caledonian Road and thrown herself from the sixth floor.
Her sister Diane Elder, 40, said: “We are just distraught and disgusted with how my sister was treated. What happened to her didn’t need to happen – the failure in care was so basic.
“My sister was such a caring and loving person. Our family will never be the same again.
“People like Finnulla, who are mentally unwell, live in torment with their illness. They are human beings who deserve to be looked after when they need help.
“We’ve received no apology for what happened. I even had to pay for a report into her death from C&I after they failed to pay for enough postage.
“Deaths like this cannot happen again.”
Coroner Mary Hassell concluded in her determination, given on April 29, that: “If the psychiatry liaison team had appreciated the full circumstances, they would have explored further with Ms Martin and offered her admission to a crisis house or hospital.
“If Ms Martin had not accepted either of these, they would have given consideration to seeking detention under a section of the Mental Health Act. Her suicide might have been prevented.”
A spokesman for C&I said: “This is a sad case where three agencies, C&I, the Metropolitan Police and the Whittington Hospital are mentioned in the Prevention of Future Death Report.
“We wish to learn from the coroner’s concerns and will work with all partners to prevent something like this from happening again.”
Philippa Davies, director of nursing and patient experience at the Whittington, said: “We are reviewing the case and coroner’s findings to ensure any opportunities to improve care and learn from this tragic death are taken.”