To view original article click here
First posted on Antidepaware
News & Star
By Phil Coleman
Published at 11:07, Saturday, 16 November 2013
A heartbroken mother has heard how staff at a hospital failed to ensure her daughter’s safety in the days before she took a fatal overdose.
She was voluntarily admitted to the Carleton Clinic in Carlisle on October 18 last year after making an attempt on her own life – by slashing her wrists and her throat, taking an overdose, and attempting to hang herself.
Yet despite her having a history of repeated self harm and suicide attempts, and without telling her family, staff at the hospital’s Hadrian’s Unit twice allowed her to have home leave.
During her first leave visit to Carlisle on October 23, she bought a razor blade and 32 tablets, which she smuggled back to her room at the hospital. Miss Gouch, of Bellgarth Gardens, Carlisle, later secretly took the pills and became ill over the following days.
Neither of the two doctors who examined her while she was on the ward, who diagnosed her with gastroenteritis, were told of her history of overdoses.
The alarm was finally raised on October 27 after a patient reported seeing Miss Gouch take an overdose.
She died two days later at The Cumberland Infirmary from multiple organ failure. During the inquest, Miss Gouch’s mother Ellen told of last two times she spoke to her daughter, a talented actress, who had studied performing arts at university but had battled depression and emotional problems.
She described her daughter’s mood the day after her admission to the Hadrian Unit on October 19.
“She was very depressed,” she said. “The next time I saw her was on October 23. I’d planned to see her that evening, but she turned up at the shop. She was doing what I call her bubbly act: pretending everything was all right but you could see in her eyes that it was not.”
She took her daughter to buy a new mobile phone battery and then for a coffee.
After leaving her mother, Miss Gouch went into the city centre and bought the razor and the pills that were later to kill her.
Mrs Gouch saw her daughter again two days later, when she returned to the shop. “She was very emotional,” she said. “Nadia appeared very unwell. She said she’d had a stomach bug – that everybody on the ward had it.”
Her daughter was in pain, on the verge of tears, and she kept apologising, Mrs Gouch told the hearing.
She continued: “I hugged her and told her everything would be all right shortly; that her medication would kick in and she’d feel a hell of a lot better. I wanted to go up to the hospital with her but she said no. She didn’t want me to catch anything and planned to sleep all day Friday.”
Asked about the kind of person Miss Gouch was, her mother replied: “Bubbly, full of life, caring; she’d give everybody the last of whatever it was. She was impulsive. She was a character, and a born actress.”
She expressed her disappointment with her daughter’s community care, saying: “She had issues of trust yet she’s had no long-term care in the community at all, with her community psychiatric nurse constantly being changed…
“Psychotherapy was never chased up.”
Recording his verdict, north and west Cumbria coroner David Roberts concluded that Miss Gouch was able to take the overdose because she was granted leave.
He acknowledged that the trust’s own investigation revealed it failed to identify the risk that she might hoard medication – something she openly admitted doing to a doctor of October 19 and staff had not safely managed giving Miss Gouch leave.
A comprehensive action plan has now been put into place to address these and related problems identified with her care.
A spokesman for Cumbria Partnership NHS Foundation Trust, which runs the Carleton Clinic and community psychiatric services, said: “We have taken this sad incident very seriously and conducted a thorough internal investigation. We are committed to continuously improving our services and to providing the best possible patient care.”