Suicidal’ woman found hanging in hospital — (Hastings and St Leonards Observer)

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Hastings and St Leonards Observer

Feb 1, 2013

A SUICIDAL woman was founded hanging in hospital just hours after nursing staff moved her from round-the-clock observation to a 15 minute watch, an inquest heard.

Natalie Clayton, who was born Stephanie Williams, 35, of Egremont Place, Hastings was found hanging at the Amberley Ward, a mental health unit at the Eastbourne DGH site.

A four-day jury inquest at Eastbourne Town Hall this week heard how she was placed on a life support machine but never regained consciousness and died six days after she was found on May 24, 2011.

The inquest started on Tuesday (January 29) and at the time of going to press evidence was still being given.

She was referred to as Stephanie throughout proceedings as this is the name her family knew her by.

The jury heard Miss Clayton’s admission to Amberley ward, run by Sussex Partnership NHS Foundation Trust, on May 14, 2011 was initially on a voluntary basis.

It had been triggered by the death of her grandmother several days earlier who she was very close to.

Coroner Alan Craze queried the decision made by medical staff to change Miss Clayton’s care plan from constant one-to-one supervision to 15-minute observations on May 24, particularly in the light of several previous suicide attempts during her time on the ward.

Mr Craze questioned Dr Priti Varsani, the doctor who carried out the initial risk assessment and drafted the care plan, when Miss Clayton was admitted to Amberley Ward. He said: “You have clear indications that she is a suicide risk and yet she goes back on 15-minute observations. Why?”

Dr Varsani replied with: “It wasn’t my decision.”

On May 16 Dr Marie-Claire Van Roon had a discussion with Ms Clayton to assess her needs.

Reading from her notes, Dr Van Roon said: “Natalie was keen to remain on eyesight observations. However, when we discussed this with ward staff they felt that 15 minute observations would be adequate because she has been approaching staff and is quite easy to engage.”

Miss Clayton, who worked part time as a cleaner, had a long history of mental health problems, self-harm, and drug use and had been diagnosed with a personality disorder, characterised by severe mood fluctuations, impulsive behaviour and difficulty dealing with stress.

She was prescribed medication including mood stabilizers and anti-depressants. She admitted to taking them only sporadically, the court heard.

Close friend and ex-partner Hollie Taylor, of Bexhill, said: “When she took her medication she was happy, balanced and stable.

“The slightest problem was hard for Natalie to deal with and brought her down drastically.”

She had on previous occasions spent time in the Woodlands mental health unit, and The Sanctuary, in Hastings.

Her mother Christine Williams, of Ashburnham Road, speaking at the inquest, said there had been problems with her daughter’s behaviour from a young age.

“She could be a bully and just wouldn’t go to school,” said Mrs Williams. “I found her behaviour quite strange. She just would not do as she was told, or would keep doing the same things over and over.”

Miss Clayton’s mental health took a dramatic turn for the worse following the death of her maternal grandmother in May 2011, someone she felt particularly close to.

This was the event that led to her being voluntarily admitted to Amberley Ward.

Her mood fluctuated and she made several attempts on her life after being admitted, talking regularly of suicide, and of joining her grandmother.

She was sectioned under the Mental Health Act on May 24 after trying to abscond from the ward.

It was that same evening around 7.30pm that Miss Clayton was found hanging in her cubicle by nurse Sally Lake.

Members of the medical staff carried out CPR, and Miss Clayton was transferred to hospital. However, she had suffered irrevocable brain damage as a result of oxygen deprivation, and never regained consciousness.

Pathologist Dr Hassan El Teraifi, who conducted the post-mortem examination, recorded the cause of death as “bronchial pneumonia due to hanging.”

Police carried out an investigation, but there were no criminal proceedings brought following Natalie Clayton’s death on May 30, 2011.

Detective sergeant Lloyd Lewis told the inquest that following a meeting with the trust after Miss Clayton’s death: “It was clear to me that Miss Clayton was assessed as being of high risk of suicide.”

The Woodlands Unit, on The Ridge, Hastings, also run by Sussex Partnership NHS Foundation Trust, was closed amid criticism of care after three patients killed themselves during 2008 and 2009.

A comprehensive review took place, and the unit was re-opened in July 2010.

The inquest into the death of Natalie Clayton is expected to conclude today (Friday). For the latest news, visit our website on