Patient took own life day after discharge due to misunderstanding, coroner says

A psychiatric patient took her own life fewer than 24 hours after being discharged from hospital without a care plan, an inquest has heard.

Sarah Adams, 64, a schizophrenic, was found dead at her home in Reading on 19 May 2022.

Berkshire Coroner's Court heard that she had been expecting a visit from an NHS crisis team on the day she died, something she believed had been arranged by Cygnet Hospital Harrow, London.

Assistant coroner for Buckinghamshire, Berkshire and Hertfordshire, Alison McCormick, who recorded a narrative conclusion, said Ms Adams was admitted as an inpatient after she attempted to take her own life on 4 April, due to her feeling "overwhelmed" and "not knowing what was happening with her health”, the hearing at Reading Town Hall heard.

Her condition was reported to have improved during her stay, but Ms McCormick said she was discharged on 18 May without a care plan.

The assistant coroner said a misunderstanding led to Ms Adams being told that twice daily visits from a crisis team, an interim measure until her care package was finalised, would begin the day she was discharged but the court heard they were not supposed to begin until the day after.

Ms McCormick said the crisis team not turning up would have caused Ms Adams to feel her care plan had "failed on day one", highlighting to the court that her previous suicide attempt had been due to her feeling out of control and not knowing what was going on.

She said this idea was supported by evidence from Ms Adams' neighbours, who reported she had told them she did not understand what medication she was supposed to take and when.

They said she "was not her usual bubbly, happy self" and that she said she "did not know how to laugh anymore." Ms Adams was found dead in her flat the following morning.  

Ms McCormick concluded that, among other factors, the misunderstanding about the crisis care team, the fact Ms Adams was discharged with five days' worth of prescription medication, and the lack of an established and consistent care team were likely to have contributed to her death.

She said she would issue a Prevention of Future Deaths (PFD) report to the hospital, Berkshire Healthcare NHS Foundation Trust and Reading Borough Council's adult social care services, to ensure adequate training is given to anyone involved in patient discharges.

A spokesperson for Cygnet said it would "always seek to ensure lessons learned are identified and shared."

The hospital added that it had been working hard to address the issues raised, including by appointing a new hospital manager and reviewing elements of their discharge policy.

Berkshire NHS Trust said it recognised it "could have done things better" and had since put ‘improved processes’ for patient discharge in place. 

A Reading Borough Council spokesperson said the authority would continue to work with the NHS trust to ensure patients were discharged safely.