A vulnerable woman died in a mental health facility after being allowed to go to the toilet on her own – despite the fact that she was meant to be watched 24 hours a day.
Georgina Hallam, from Nottingham, swallowed a foreign object in an act of self-harm when a healthcare assistant decided that the 47-year-old could use the bathroom at Bradley Complex Care Apartments in Grimsby, Lincolnshire, where she lived, without supervision.
An inquest held at Greater Lincolnshire Coroner’s Court into the circumstances of her death on 8 August 2022 found that processes to ensure that the right staff were in place to care for Georgina were not carried out to the required standard.
Ms Hallam, who was born with a speech impediment, partial deafness, cerebral palsy, and learning disabilities, lived on her own in Jacksdale, north Nottinghamshire, until the Covid-19 pandemic.
In January 2022, after a period of worsening behavioural issues and self-harm incidents, partly contributed to by disruption to her social support schedule, she moved into Bradley Apartments, run by Elysium Healthcare Ltd.
During her time there, her behaviour worsened, and she began to self-harm more frequently and more severely.
She was placed on 24/7 one-to-one observations, meaning that staff needed to watch her all day and night, including when she washed and went to the toilet.
Lawyers representing Ms Hallam’s family at the inquest said that her care plan was “very clear” and that her need for one-to-one observations had even been explained to Georgina herself due to her history of self-harm.
On the night of 4 August 2022, she went into a toilet alone with permission from a male agency worker, who was not a regular, permanent staff member at the apartments and who was unfamiliar with Ms Hallam.
He was on duty because steps were not taken to “manage shift cover adequately,” coroner Jayne Wilkes said.
While in the toilet, she swallowed an object given to her by the agency worker.
Five minutes later, questioning where Ms Hallam was and being told that she was in the toilet, a female staff member went in and found Ms Hallam lying on the floor, holding her stomach and in “significant distress”.
She was carried out of the toilet and to her bedroom, but by the time emergency services arrived, she had no pulse and was in cardiac arrest.
Paramedics removed the item from her throat and administered CPR, after which her pulse returned.
She was transported to hospital, but it was found that her brain had been starved of blood and oxygen, and she died three days later.
Ms Hallam’s inquest heard that Nottinghamshire County Council, which was responsible for her social care when she was living alone, had not assessed her mental capacity correctly, leading to those involved in her care misunderstanding her needs.
Staff at Bradley Apartments were not reminded of the need to be vigilant in Ms Hallam’s care.
There were “insufficient precautions in place” to address the known risks of Ms Hallam self-harming, the coroner said.
Ultimately, Ms Hallam’s death was recorded as “misadventure”.
The inquest heard that the charity worker, who presented with emotional dysfunction, likely did not intend to end her life and was instead “attention-seeking” a care response, believing that she would be saved.
She would not emotionally grasp or understand the potentially fatal consequences of her actions.
Her brother Anthony said: “I find it hard to comprehend how a facility that is supposed to specialise in looking after vulnerable people like Georgina can fail to follow care plans that have been specifically put in place to protect them.
“This was clearly a failure to follow procedures. Had the care plan been followed, Georgina would never have had the opportunity to do what she did, and in the longer term, she could have secured the help she needed.
“Lessons must be learned, as it is these kinds of mistakes that lead to families losing their loved ones in entirely avoidable circumstances.”
Iftikhar Manzoor, from Hudgell Solicitors, on behalf of Ms Hallam’s family, said: “Georgina was completely let down. She was in a specialist facility because she was a threat to her own safety. It was meant to be a place where she would be kept safe by a specialist team.
“As this could upset Georgina, as she felt like staff were always watching her, they were told to remind her that it was being done to keep her safe. A life was lost here because the most basic of instructions were not followed.
“There was no effective system in place to ensure an adequate number of female workers on site during each shift and that agency staff, or staff covering from other roles, were properly briefed regarding patient care plans, particularly for patients with significant suicidal intent for whom critical risk mitigation measures had been put in place. These were inexcusable failings.”
A spokesperson for Elysium Healthcare Ltd said: “We continue to send our deepest condolences to Georgina’s family and friends following her tragic death in 2022.
“A full and thorough investigation was undertaken at the time of this incident, and as a consequence, improvements were made regarding observation policies and staff training.
“At the conclusion of the inquest, the coroner was satisfied that Bradley Apartments is a safe place for some of the most vulnerable members of our community to live. The service was recently inspected by the CQC and rated as ‘Good’.”
A spokesman for Nottinghamshire County Council said: “We extend our deepest sympathies to Georgina Hallam’s family and all those affected by her tragic death. The Coroner’s formal conclusion was that Georgina died as a result of misadventure following a self-inflicted act.
“The inquest highlighted the complexity of her needs and the challenging circumstances surrounding her care.
“We are reviewing the Coroner’s findings carefully to ensure that lessons are learned and improvements are made across relevant processes. Given the sensitive nature of this case, it would not be appropriate to comment further at this time.”
