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A coroner says she has ‘grave concern’ over staffing levels at a mental health hospital where neglect contributed to the death of a Mapperley woman in their care.

Sophie Towle died from a large blood clot in her lung on May 27, 2024 at Sherwood Oaks Hospital in Mansfield, run by Nottinghamshire Healthcare NHS Foundation Trust.

The jury at her inquest found that she was subject to substandard care and that a number of failures by the people and authorities caring for her had probably played a part in her passing.

On Friday, October 31, coroner Alexandra Pountney published her Preventions of Future Deaths report – a paper made by a coroner when they believe that action needs to be taken by an authority to prevent future deaths.

Within it, Ms Pountney alludes to hearing from “numerous witnesses” at the inquest that staffing levels on Fir Ward – the ward on which Sophie stayed – were insufficient at the time she died, and still are now.

“The result of that, I am told, is that the wards cannot run safely and patient care and safety [is] negatively impacted,” Ms Pountney has written in the report.

“Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require.

“This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board, that the wards are not functioning safely and that patients are at risk of death as a result.”

The report also lists four other matters of concern, relating to both Nottinghamshire Healthcare NHS Foundation Trust (NCHT) and Sherwood Forest Hospitals Foundation Trust, which runs Kings Mill Hospital in Mansfield.

Sophie was seen at Kings Mill Hospital on numerous occasions after she had self-harmed by inserting a foreign object into a wound on her leg – but orthopaedic staff made the decision not to take the object out for clinical reasons.

The injury caused by her inserting the object in her leg caused her pain leading to her being unable to walk, and her immobility was part of the reason a blood clot formed that caused her death.

The report says: “I heard evidence that it would have been beneficial in Sophie’s case for there to have been a meeting between Sophie’s psychiatric team and her physical health team at Kings Mill.”

The report explains that Sophie’s mental health team was keen for the foreign object to be removed and were satisfied they could implement a policy to stop Sophie from putting any more objects in there.

Contrastingly, one of the main concerns of the doctors at King’s Mill was that if they took the foreign object out, Sophie would just put something else in the wound instead.

But the teams at Kings Mill and Sherwood Oaks never had a meeting to discuss it.

“There is no mechanism for arranging meetings, or for any liaison between mental and physical teams in such cases,” the report says.

“Similarly, there is no policy or procedure which prompts either team to even consider a meeting or even just picking up the phone for a consult.”

The coroner also voiced her concerns in the report about Nottinghamshire Healthcare’s blood clot risk assessment policy.

Staff at NCHT who appeared as witnesses at the inquest told the coroner they did know of a policy and recognised it as the latest policy when they were shown a version.

But it turned out they were familiar with a previous one – not the most recently updated one, which was published six months ago.

The coroner said she was concerned that staff did “not have a proper working knowledge of the current local policy” and as a result, training around the policy was not “robust” or was”not properly being engaged with” by staff.

The disbanding of NCHT’s Personality Disorder Hub was also raised in the report.

The coroner said that neither a witness who worked within that disbanded hub, nor the witness who was in charge of NCHT’s policy, could explain the service that had replaced the Hub.

She said: “Given the current inquiry into Mental Health Services in Nottinghamshire, and particularly the care of those patients with personality disorders within the service, I am concerned about the lack of clarity within the Trust as to the current position and level of service available to patients with personality disorders.”

Separately, she also raised an issue with Sherwood Forest Hospital’s foreign object policy, saying its content was “unspecific”, the language used was “vague”, and that it did “not provide clear guidance for medical professionals”.

She called it “not a robust policy in its terms”, and also noted that it does not make any reference at all to the consultation of mental health services – despite the fact that it acknowledges that most cases involving the insertion of a foreign object into a body involved a patient with mental health condition.

The report said: “I am concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.”

On all points bar Sherwood Forest Hospital’s foreign object policy, the coroner said that in her opinion, further deaths could occur unless action was taken to change.

As well as being sent to NCHT and Sherwood Forest Hospitals, the report was sent to the Department for Health and Social Care.