Deborah Crompton who was 52 years old was diagnosed with paranoid schizophrenia. She spent a considerable period of time in a low secure unit. In January 2017 she was transferred to a community based setting known as the Jigsaw Independent Hospital in Didsbury, South Manchester.
Deborah had a history of absconding and had absconded multiple times in the weeks leading up to her death. On 4th August 2017, she returned late from unescorted leave in the community under the influence of alcohol. The responsible clinician advised the nurse in charge that all leave was to be suspended to include rescinding unsecure garden access she had been granted. Deborah’s care plan was not updated.
On 9th August 2017 Deborah took unescorted leave despite Section 17 leave not being in place. The Jury concluded that “this abscontion was enabled due to a systemic failure to follow both Section 17 Policy and the hospital’s interpretation of the Code of Practice which granted Deborah the opportunity to abscond with fatal consequences.”
On 15th August 2017, Deborah absconded from the hospital whilst on an unescorted cigarette break in the hospital garden. She was reported missing to Greater Manchester Police and was last seen at Manchester Town Hall that evening when she handed a note in at the police station. Deborah was not seen again and on 9th November 2017 her body was recovered from the river Irk. The time of death is not known, but on the best available evidence was caused by drowning approximately 2-3 months prior.
The Jury found that the following factors contributed to Deborah’s death:
The hospital’s policy at the time of the events on unescorted garden access were inconsistent with the intentions of the Code of Practice;
Mixed practice in recording and using Section 17 forms resulted in the patient having access to the unsecure garden, authorised by the Registered Mental Health Nurse and contrary to the responsible Clinician’s instructions;
Despite the Registered Mental Health Nurse’s admitted failure to check the Section 17 form or care plan. Evidence suggests such practices were common place within the establishment;
Failure to adequately complete and document observations diligently resulted in a delay in identifying Deborah was missing;
Systematic failure to follow both Section 17 policy and the hospital’s interpretation of the Code of Practice which granted Deborah the opportunity to abscond which resulted in fatal consequences.
Our specialist inquest team represented Deborah’s family in the inquest proceedings and were successful in securing exceptional case funding to enable them to be legally represented at the inquest hearing.
To speak to a member of Farleys’ inquest team please call 0845 287 0939 or submit your enquiry through our online contact form.
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