A woman was watched dying for an hour by NHS staff who wrongly believed she was asleep, an inquest heard.
Shannara Donnelly, 22, was considered at risk of self-harm and was meant to kept an eye on by staff ‘at all times’ while at Chase Farm Hospital in Enfield, north London.
Ms Donnelly, who was known as Jade, was observed by nurses watching CCTV cameras , who missed her collapsing to the floor in her room at the unit.
Jurors heard that staff saw her unresponsive on the ground for an hour but, presuming she was sleeping, failed to act. Jade died ‘by her own hands’, the inquest heard.
Jade’s condition meant she required ‘one-to-one’ care and continuous observation ’24/7, seven days a week’, the inquest was told. However, CCTV footage played to the court showed staff only observing her through peephole windows and on cameras.
Barnet, Enfield and Haringey Mental Health Trust admitted that medical staff, who were also looking after another person in the facility at the time, had failed to carry out the required checks and that Jade was insufficiently monitored.
Its director, Mark Pritchard admitted ‘shortcomings’ in Jade’s care.
‘I want to offer my sincere condolences, on behalf of the Trust, for the shortcomings in Jade’s death’, he told Jade’s family.
Jane Basemera, Jade’s allocated nurse on the day of her death, told the court the patient would have lived had she been on Level Four observations.
Ms Basemera, who broke down in tears during her evidence, said: ‘Arms length observations would have saved Jade.’
The nurse added that the unit had staffing issues and that Jade should have had two members of staff looking after her.
She admitted the she had been told the patient was on the floor, but not that she had collapsed.
The inquest heard that Jade was readmitted to Chase Farm against the instructions in her medical documents, which warned of a previous incident in the hospital.
Days before her readmission she had been arrested after threatening to harm herself and telling police officers she ‘wanted to die’, jurors were told.
Staff on shift at the time of Jade’s death were also found to be incompliant with their life support training and of the two oxygen tanks kept at the unit, one was empty and the other missing an essential attachment.
The court also heard that the 22-year-old had been angered by a doctor’s refusal to discharge her from unit.
But Jade’s mother, Kerry said that conversations with her daughter on the day she died were inconsistent with someone about to take their life.
She said Jade was a ‘very popular’ girl at school who ‘loved to make people laugh’.
Paying tribute to her late daughter, Ms Donnelly said: ‘Jade always liked doing different things and whatever she did she generally put her heart and soul into it.
‘Jade was a very special person and somehow people were just attracted to her. Jade loved to laugh and even more loved to make other people laugh.
‘To Jade, all life was important and special. Jade loved her family and friends, and she would do anything for anyone sometimes even to the detriment of herself.’
But the young woman had also struggled through lockdown and had recently lost three close family members, her mother added.
Jade was diagnosed with ADHD and faced bullying at school, leading her mother to home-school her, before she later attended Winchmore and Enfield County schools.
She was an active member of both the Army and Police cadets, as well as being a member of the Royal British Legion.
Jade had reported previous sexual abuse, had struggled with alcohol abuse and sometimes heard ‘voices’ in her head.
Ms Donnelly explained that Jade had also struggled during lockdown and had recently lost three close members of her family before her death.
‘The pain was sometimes just too unbearable for her,’ she continued. ‘As such, she had stayed in different places whilst she tried to get help and where she would be safe.
‘Tragically, whilst in [the care of Chase Farm Hospital] on June 19, a very beautiful leaf fell from our family tree, but the memories of Jade will remain deep-rooted in our hearts forever.’
Hospital guidelines stated that patients should be monitored ‘attentively’ and that although CCTV observation could be used to support staff, ‘it should not be used in place of observations and engagement’.
Jade’s Level Three care plan specified she should have been within eyesight ‘at all times’, except for when she was in the bathroom, when staff should have been in verbal contact with her, the inquest heard.
Asked if he saw any of the required Level Three observations on the CCTV recording, Trust director Mr Pritchard replied: ‘The bulk of it, I would say no. The overarching answer is no.’
Area Coroner Tony Murphy said: ‘It does appear that some very significant events that occurred to Jade during the time in the bathroom were missed.’
The inquest continues.