Unit where Laura Hill had been treated

THE REASON why 21-year-old Laura Hill took her own life ‘remains unclear’, the deputy coroner for Pembrokeshire has ruled. 

The body of Laura Hill, 21, from Neyland, was found by members of the public on 17 December, 2012.

At the inquest on Friday (Feb 20), Deputy Coroner Gareth Lewis said: “Miss Hill suspended herself from the branch of a tree in a wooden area near to Withybush Hospital, but the question of intent remains unclear”.

Tragic : Laura Hill

Earlier in 2012, Miss Hill, who was from Neyland, had suffered the loss of her baby son and she had struggled to come to terms with this.

She had been admitted to Withybush Hospital on December 11, after taking an overdose of prescription tablets and she was later transferred to Bro Cerwyn Hospital.

However, on the night of December 16, Laura absconded and she was found hanged the following morning by members of the public.

Among his findings, the deputy coroner highlighted evidence from a psychiatrist, Dr Shubulade Smith, who said that Miss Hill was suffering from Emotionally Unstable Personality Disorder (EUPD).

Reading out the facts of the case, Gareth Lewis said: “On December 11, 2012, Miss Hill was admitted to Withybush General Hospital after taking a large overdose of prescription tablets.

“Miss Hill remained as an inpatient at the Hospital until December 15, at which point she was transferred to Bro Cerwyn Hospital.

“On arrival at the hospital it was felt that she would benefit from admission in view of her depression, substance misuse, unresolved bereavement issues and her recent suicide attempt.

“Dr Athithan described her as having a varied suicide risk and placed her on level two 15 observations. She was described as bright, jovial and interacted well with others.

“At 19:15, Miss Hill asked to leave the ward in order to source some heroin. Staff on the ward tried to dissuade Miss Hill from leaving but she was adamant that she wanted to leave and she discharged herself against medical advice.

“In the early of hours of December 16, 2012, police had cause to carry out a welfare check in relation to Miss Hill. Officers were concerned that Miss Hill presented a danger to herself and detained her under section 136 of the Mental Health Act.

“Miss Hill was readmitted to the ward at 02.29hrs on December 16. On arrival she was assessed by Dr Athithan as being emotional, in a distressed state, sobbing and tearful. He suggested that if she tried to leave the ward they should use their holding powers under the Mental Health Act.

“At 14:45 on December 16, Miss Hill walked out of the ward and left the grounds of the hospital. Miss Hill was followed by two members of staff who persuaded her to return to the ward.

“Shortly after taking her medication at 18:15, Miss Hill absconded from the ward again and could not be located. Police were alerted to this and an immediate search was undertaken.

“Miss Hill’s body was found by members of the public at approximately 07:55 on December 17, 2012. She was suspended from a branch of tree with a blue nylon rope around her neck. The cause of death from a post mortem examination was found to be hanging.

“My findings are as follows: The decision to allow Miss Hill to leave the ward on December 15 against medical advice was probably right even if undesirable in the circumstances.

“When Miss Hill was returned to the ward by police there was a significant breakdown in the exchange of information under the section 136 handing over process.

“There was a failure to report Miss Hill’s attempt to abscond at 14:45 on December 16 to Dr Athithan despite his recommendation that if Miss Hill tried to abscond, consideration needed to be given to the use of holding powers. There was a clear lack of appreciation amongst the staff on the ward as to the meaning of the word abscond and because Miss Hill came back to the ward this was not perceived to be an attempt to abscond.

“Miss Hill’s mental state should have been, but was not, reviewed when she returned to the ward after absconding.

“The staff failed to appreciate that level two 15 observations were clearly insufficient to prevent Miss Hill leaving the ward. Miss Hill was only seen to be leaving the ward by fellow patients.

“There needed to be a system to monitor access and egress from the ward. Dr Smith commented during his evidence: ‘You cannot just let people come and go as they please, there needs to be someone in control of the door’, if this was in place it would have been considerably more difficult  for Miss Hill to have absconded from the ward.

“Staffing levels at the ward were such that it would have been difficult to put Miss Hill on level 3 even if this had been considered appropriate.

“There was a lack of joined up thinking between the members of the mental health teams working with Miss Hill. Dr Smith felt that the mental health teams never looked behind Miss Hill’s substance misuse. Dr Smith commented in his evidence that ‘undoubtedly, Miss Hill was suffering from Emotionally Unstable Personality Disorder’.

“One of the main features of EUPD is a tendency to act impulsively without consideration of the consequences. In her evidence she stated that it was very difficult to say whether she intended to kill herself.

At the end of the inquest Mr Lewis added that he would be exercising his powers under regulation 28 to send the report to prevent future deaths to the Hywel Dda Health Board and Welsh Government’s Improving Patient Safety team. He highlighted that his letter would surround training needs, lack of policy regarding access and egress and staffing ratios.