Same failings each time…. NEPFT you are a joke….people come to you to be kept safe….clearly this is not being done…..how loud must we keep shouting…..this is criminal behaviour!!!!!!!!!!!
A SHORTAGE of beds and failures by Colchester’s mental health trust may have contributed to a woman’s death, an inquest heard.…
A serious incident investigation was carried out after Dorota Kijowska, 36, was found hanged from an unlocked loft hatch at The Lakes, Turner Road, Colchester.
The jury heard Mrs Kijowska, a mother and wife with recurrent depression, was returning from leave but her bed had been given away and there were no beds available.No formal risk assessment was carried out when she returned, there was inadequate observation by staff, a breakdown in communication about the plans for her and the building was not safe enough.Mrs Kijowska, from Fordham, attempted suicide on March 7 and March 9 last year, the inquest heard.She was admitted to The Lakes voluntarily on March 10.
On March 20 she went on leave to spend time with her family.
On March 23 she returned and wanted to stay to receive more help from the unit but was told she would be going out on leave again.
The inquest heard she broke down, threatened to kill herself and spent the next hour sitting on the floor of the ward crying.
Shortly after she was found dead hanged by a scarf in a toilet cubicle at the unit, run by North Essex Partnership Foundation Trust.
Elizabeth Wells, acute operations service manager for the trust, told the inquest yesterday changes have been made.
On Monday, March 23, there were 22 patients requiring beds and 18 beds available.
Ms Wells said: “We need to find a bed or two most days that we do not have.
“We have extraordinary bed pressures at the moment.”
Before the incident risk assessments were not carried out when patients returned from leave but this has been changed.
Ms Wells said there had not been “an appropriate level of observation” while Mrs Kijowska was waiting at the ward.
There were also conflicting accounts from staff about whether Mrs Kijowska was still due to return home after making suicidal threats with different reports from different staff members stating different plans.
Ms Wells told Her Majesty’s Senior Coroner Caroline Beasley-Murray the review procedure has since changed.
And she revealed all loft hatches are now locked and taps are being removed, and replaced with sensors, to reduce the risks.
Wow we….things are being changed….!!!!!!
poor Dorota died a year ago….why weren’t things changed immediately after this??? And how do we know things are being changed…..?????
NEPFT lied to us before and told us all recommendations had been actioned in 2008 after Ben Morris’s death and then again after Matthew Leahys death in 2012. It’s now 2016 and still no confirmation that the changes recommended have been completed!!!!!
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