Winwick hospital criticised after woman died swallowing paper towels

Stacey Watling, from Stretford, was desperate to be moved out of the mental health facility and back into the community but no suitable care package could be located by Trafford social services.

A four-day inquest at Cheshire Coroner's Court led a jury to conclude Stacey died as a result of misadventure contributed by neglect at Hollins Park, now run by North West Boroughs Healthcare NHS Foundation Trust.

Despite measures in place, which meant Stacey was should have been under observation by two carers at all times, witnesses said the 24-year-old was 'left alone for some time' when she died in 2017.

Now hospital bosses have apologised 'wholeheartedly' for the shortcomings in care.

Denise Watling, Stacey's mum, said her daughter was 'treated like a prisoner' and told the court how she 'deteriorated quickly' when she was moved into the mental health facilities.

She said: "In the 20 years of her living at home with her family, she never once tried to swallow a foreign object – she didn't have mental health problems.

"This all started when she was moved to Jigsaw Hospital and Hollins Park Hospital.

"Swallowing these things meant the ambulance came and took her for a day out but she didn't understand the concept of death and how doing these things could mean she wouldn't wake up.

"She hated being restricted in what she could do."

The court heard how Stacey swallowed items such as plasters, coins, batteries and tissue paper while she resided on the Byron Ward.

She had been detained under the mental health act and had been in Hollins Park since November 2015 and was still a patient in May 2017 when she died.

Despite efforts to discharge Stacey from the hospital, a suitable care package could not be found that would meet her 'complex needs' in the community.

This is something which caused 'a great deal of stress' for Stacey, who would often ask medical staff and her family 'when she was going home'.

Denise said: "Stacey was a kind and generous person with a wicked sense of humour who reacted to the situations she found herself in.

"She was treated like a prisoner in Hollins Park and had not committed any crimes other than being born with a condition.

"She wanted to live life like other people, be included and have her own place near her family.

"Stacey was a little girl who wanted a normal life but she was treated like an adult with a mental illness.

"The last four years were not good to her, we just went round and round in circles.

"She would have coped in supported living, she just needed the right support which she never got.

"It was other people who thought they knew best."

The jury were told that Stacey was born with various conditions such as Bulbar palsy and had difficulty eating, drinking and talking when she was young.

In September 2012, aged 20, she was given supported living accommodation in Urmston before being moved to Jigsaw Hospital a year later after being detained under the mental health act.

While a patient at Jigsaw, Stacey drank so much water that she suffered a seizure and ended up in intensive care.

She was then transferred out of Wythenshawe Hospital straight to Hollins Park which she found 'difficult' because she had never been to Warrington.

Denise said she was assured Hollins Park would be a short term placement for her daughter and a range of alternatives were being discussed.

Consultant psychiatrist Ms Gladstone, who looked after Stacey while she was a patient at Hollins Park, told the court that Stacey 'didn't like' being in the hospital.

She said: "She found having to be under observation restrictive and would often react to situations.

"Sometimes she became aggressive and abusive towards other people and staff when she was stressed.

"She did take part in social activities such as swimming, shopping, going to the beach and bowling.

"She needed two people observing her at all times because her behaviour was unpredictable."

Ms Gladstone also described the seclusion room where Stacey was often moved to when other methods of treating her and de-escalating situations did not work.

This was not the first option for when Stacey had a meltdown but she would need intravascular calming medication.

The day before she collapsed, Stacey made 80 phone calls and text messages to her parents asking if they were coming to visit her.

Mr MacNamara, the Watling family's barrister, asked how she could have made those calls when she should have been under constant observation.

Ms Gladstone referred to the two instances where staff had made notes about Stacey's phone activity but said it was hard to know if she was making calls as she would often listen to music on her phone with her headphones on.

The barrister also asked whether the Byron Ward was the most suitable for Stacey when she only had one condition which classed as a mental disorder.

Ms Gladstone explained that Stacey's challenging learning behaviour met the criteria for a moderate learning disability and she was initially referred as a short-term patient.

A serious incident report from North West Boroughs Healthcare NHS Foundation Trust cites the Byron Ward was not appropriate for her.

On May 8, 2017 Stacey was rushed to Warrington Hospital but despite efforts, she never recovered from the hypoxic brain injury and died three weeks later.

Gail Briers, chief nurse and deputy chief executive at North West Boroughs Healthcare NHS Foundation Trust, said:

“I would like to offer my sincere condolences to Stacey’s family and apologise wholeheartedly for the shortcomings in her care whilst on Byron Ward.

“A comprehensive investigation took place immediately after Stacey’s death and changes have been made to help minimise the risk of any similar incidents occurring in the future.

“We have strengthened and clarified our observation, safety and engagement procedure, and this now provides greater clarity around what each observation level means. Increasing staff understanding and awareness of this procedure is now taking place as a priority through daily team safety meetings and face-to-face training.”

“We have also carried out a full staffing review on Byron Ward and have introduced daily staffing huddles with our senior leadership team. This is to ensure staff levels and skill mix are sufficient to meet the needs of the patients on the ward that day.”

Acting on behalf of the Watling family Laura Zander, clinical negligence solicitor of Price Slater Gawne said: “This is a tragic case which has sadly resulted in the avoidable death of a vulnerable young girl. 

"The coroner is now considering what recommendations can be made to ensure that this does not happen again and will be liaising with the Watling family in relation to this.

"Stacey was a vibrant, fun-loving girl who was dearly loved by her family and friends. 

"The inquest heard evidence that whilst she had been placed on the Byron Ward this was not a suitable placement for Stacey.  It was agreed that she required a supported placement within the community to enable her to have as much independence as possible. 

"A placement could not be found for Stacey and efforts to find a placement continued up until her death. There is a national shortage of placements available for vulnerable young adults within the mental health system, which is simply unacceptable.”