Kimberley Parsons

On 28th March 2014 commenced an investigation into the death of Kimberley Jane Elizabeth PARSONS, Aged 23. The investigation concluded at the end of the inquest on 6"h February. The conclusion of the Jury was that the medical cause of death was Ia) Hypoxic brain injury; 1b) Hanging and the conclusion was that of an Accidental death.

Since 2008 Ms. Parsons had suffered with mental health problems with suicidal ideation In 2010 she was diagnosed with borderline personality disorder and in May 2010 she was admitted for the first time to Sycamore Ward, Hillview Lodge, Bath owing to suicidal intent; From that time until early 2014 Ms. Parsons took a number of overdoses of medication, self-harmed by cutting herself as well as trying to set herself on Following earlier admissions to Sycamore Ward in August 2013, November 2013 and January 2014 Ms. Parsons was again admitted to Sycamore Ward; Hillview Lodge, Bath, under Section 2, Mental Health Act 1983 on 7th March 2014. On admission it was noted that she had a high level of risk of self-harm in the context of a relapse of her mental health condition; Her prescribed medication on admission was mirtazapine tablets 45mg once daily, quetiapine tablets 50mg once daily and lorazepam 1 2 mg when required (within the dosage range of the British National Formulary) Ms_ Parsons remained distressed, low in mood and expressing a wish to die_ On 9th March 2014 Ms Parsons self-harmed on the ward by cutting her wrist with broken crockery. The wounds were treated appropriately by nursing staff on the ward Consultant Psychiatrist; reported that Ms. Parsons continued to express strong suicidal desires and was not wishing to engage On 12th March 2014 the staff nurse noted that Ms_ Parsons had again self-harmed on the ward and had used piece of broken crockery she had found in the garden to make a superficial to her wrist. On 14th March 2014 Ward Manager; Sycamore Ward, discussed with Ms. Parsons her recent attempts at self-harm on the ward and asked her how best she could be prevented from coming_to harm and to prevent her presentation from escalating: In evidence Istated that she asked Ms. Parsons whether staff allowing and supporting her to self-harm help her in any way; would it ease frustration, anger or urges to harm herself: Ireferred to 'evidence' suggesting that this approach can reduce the risk of infection by avoiding the person using dirty utensils and also that trying to stop an individual from self-harming could lead to more fatal and explorative methods of harming_ However;in evidence Iwas unable to identify any other examples where fire. very cut this approach had been adopted in the unit and she could not provide any references to peer-reviewed papers published in the professional literature: Importantly accepted that she had not discussed this matter with or any of the other medical staff, neither prior to nor after; her discussion with Ms Parsons In addition she made no record of the discussion in the medical records _ was asked whether he was aware of any evidence of this approach being adopted in such patients and in evidence he confirmed that he was not aware of any published papers in the professional journals to which he had access. Notwithstanding this discussion between and Ms_ Parsons there was no evidence that subsequently there had been any assistance provided to Ms. Parsons in the manner described by During the early hours of 16th March 2014 Ms; Parsons was found hanging in her room having used an item of clothing as a ligature Attempts at resuscitation were undertaken by ward staff and the paramedics were summoned: Ms_ Parsons was transferred to the Royal United Hospital, Bath where she was admitted to the Intensive Care Unit However; despite all efforts she died as a result of injuries on 24th March 2014.

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