Alison Draper

On 10hh September 2014 an investigation into the death of Alison Jane DRAPER, Aged 45 commenced. The investigation concluded at the end of the inquest on 28h May 2015. The conclusion of the inquest was: Medical Cause_of Death la Hypoxic brain injury Ib Neck ligature Ic Mental health issues Conclusion Narrative Alison Draper was found ligatured in her bedroom whilst a patient on Juniper Ward, she died from the injuries she sustained, her intention is unknown: She was on 10 minute observations at the time and should have been checked at 7pm she was not found in her bedroom until approximately 7.12pm which was 20 minutes approximately from the previous check; this resulted in a lost opportunity to render medical care , attention or treatment

Ms. Draper had a history of mental health problems over a number years which included several attempts to self-harm and take her life. On 8th August 2014 she was admitted to Elizabeth Casson House at Callington Road Hospital, she was detained under Section 2 of the Mental Health Act, During this admission she made 8 attempts to take her life by ligature: The risk of self-harmlsuicide was described by her Consultant as chronic and impulsive. On 5lh September 2014 Ms_ Draper was stepped down from the Psychiatric Intensive Care unit to Juniper Ward (an open acute unit)_ On 7lh September a Health Care Assistant was tasked with carrying 10 minutes observations on Ms. Draper: She last observed her at 18.50 in the garden: At the 7pm check the same Health Care Assistant was also tasked with carrying out the hourly checks for all 19 patients on the ward, two of whom were on 10 minute observations, one of whom was Ms. Draper: It is unclear how the checks_ were actually carried out as the_witness could not remember and being out but at approximately 7:10/7:12 pm she asked for assistance from two other members of staff Ms Draper was found in her own bedroom having ligatured herself: Ms. Draper was taken to Hospital but suffered an un-survivable hypoxic brain injury

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: