Elizabeth Collins was found unresponsive in her room on the Oak Ward, a secure mental health unit at Royal Bolton Hospital, on the 4th August 2019. She was pronounced deceased after resuscitation efforts were unsuccessful.
The family had raised concerns about the management of her care whilst under Greater Manchester Mental Health (GMMH) and in particular the medication she was given and observation levels thereafter.
Assistant Coroner Mr Frodsham sitting with a jury at Greater Manchester West Coroner’s Court heard how Miss Collins had been under the care of psychiatric services for many years and had previously been admitted to hospital under the Mental Health Act.
Background
In April 2019 following a deterioration in her mental health, Miss Collins was admitted under Section 3 of the Mental Health Act. Elizabeth had been diagnosed with paranoid schizophrenia and had a significant history of abuse of illicit substances, including heroin for which she received prescribed methadone medication to manage her withdrawal.
On the 2nd August 2019, Miss Collins was granted Section 17 escorted leave from Salford Royal Hospital and she absconded; she later returned to hospital intoxicated on the evening of 3rd August 2019, by which point her bed had been re-allocted to another patient. Her regular medication was omitted due to her intoxication, and she was placed on 15-minute observations. She was then moved to the Oak Ward at Bolton Royal Hospital, arriving shortly after midnight on the 4th August.
Contrary to GMMH Trust policy Miss Collins was given her daily dose of 60mls methadone at 01:30 which should have been omitted whilst she was monitored for withdrawal. Some 12 hours later at 13:30 Miss Collins was administered another 60mls dose of methadone in breach of GMMH Trust policy.
Miss Collins’ presentation was such that she should have been monitored with increased observations and physical observations carried out. Had a set of physical observations been completed it is more likely than not that these would have been abnormal and the matter escalated to a doctor.
At 16:00 Elizabeth was observed on her knees, unconscious and snoring. In contrary to the completed observation log, insufficient observations were logged for the hours of 17:00 – 19:00. At 19:00 Elizabeth was observed and again at 19:15 where she was noted to be in a similar state but in the prone position on the floor. She was then assessed and it became apparent Elizabeth was unresponsive, cold to touch and not breathing, and CPR was commenced.
The jury concluded in their narrative conclusion that on the balance of probabilities, had Miss Collins’s physical health monitoring been increased and a doctor called to review her following the check at 15:00 she would not have died when she did.
The jury found in conclusion that “Elizabeth Collins died as the consequence of combined toxicity of her prescribed medication and illicitly obtained substances, contributed to by neglect.”
The family of Miss Collins were represented by Andrew Bridgman of St Johns Buildings Chambers and Mr David Corrigan of Farleys Solicitors.
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