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'Failures by mental health staff' the root cause of patient Sally Ann Vye's suicide, Leicester inquest told


The "failure of a number of specific" mental health staff was the root cause of a woman taking her own life, a coroner has ruled.

Leicester coroner Catherine Mason said Sally Ann Vye jumped from cliffs at Beachy Head, Sussex, while her mind was unbalanced, on June 20 last year.

The previous day, a care support worker had allowed Miss Vye, 39, to walk out of the Bradgate Unit at Glenfield Hospital, contrary to policy.

A four-day hearing at Leicester Town Hall heard her absence was not discovered until nearly eight hours later, following a call from her parents.

After the verdict, her father, Ronald Vye, of Tennyson Way, Melton, read a statement on behalf of himself and his wife Marilyn.

He said: "Sally was very kind, considerate and generous. She made us into a happy family, sharing many wonderful experiences together that will give us fond memories in time.

"This inquest has heard that on June 19 a number of staff on the Beaumont Ward, from the top to the bottom, failed to do the jobs that they were paid for.

"As a result, Sally was unaccounted for for eight hours before she was reported missing.

"She was therefore denied the chance of being intercepted before she reached Beachy Head.

"Nothing can bring Sally back, Marilyn and I will miss her for the rest of our lives."

The inquest was told a number of policies and procedures had been breached by staff on the unit's Beaumont Ward.

One person said she saw nurses celebrating a doctor's birthday with cake at about the time Miss Vye absconded, and that the ward was chaotic at the time because of problems with other patients. This was denied by a senior manager.

Mrs Mason said there was a failure to properly observe and record details of Miss Vye's mental condition.

She said when Miss Vye absconded it was known or should have been known there was a real risk of suicide.

Mrs Mason said: "Yet the observations and authorised period of unescorted leave specifically prescribed were not followed. This failure had a clear and direct causal connection with Miss Vye not being found sooner.

"The root cause of this incident is a failure of a number of specific staff to follow the systems and processes in place to monitor Miss Vye's leave and her whereabouts."

Mrs Mason said she was pleased to hear of significant improvements at the Bradgate Unit since the tragedy.

The inquest was one of seven into deaths of mental health patients in the care of the Leicestershire Partnership NHS Trust between November 2010 and June 2012, with one still to be heard.

It has emerged the coroner will investigate three further cases of mental health patients who died in the trust's care.

Recording a narrative verdict, Mrs Mason said: "Despite the known existence of a real and immediate risk to Miss Vye's life from self-harm, she was able to go missing, undetected, for nearly eight hours."

However, she said it would never be known if earlier realisation of her disappearance could have prevented her death.

Paul Miller, divisional director for adult mental health services at the trust, said: "We fully accept the coroner's verdict.

"A number of errors by individuals contributed to Miss Vye's death, which fell well short of the level of care we expect from our staff.

"I can provide reassurance that we took immediate action at the time and have implemented recommendations and actions to make sure we reduce the risk of a tragic incident such as this happening again."

'Failures by mental health staff' the root cause of patient Sally Ann Vye's suicide, Leicester inquest told

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