Failed checks and falsified records as nurse died within hours of being admitted to Glenbourne

PSYCHIATRIC unit staff failed to complete key safety checks and falsified records around the death of a patient found hanged, an inquest heard.

Elizabeth Watts died within 12 hours of being admitted to the NHS Glenbourne Unit in Plymouth.

The 38-year-old nurse had been sectioned under the Mental Health Act after taking an overdose of tablets.

She was suffering from depression deepened by widely-publicised allegations she had sex with a patient, the inquest was told yesterday.

A catalogue of questions about the night of her death was raised at the opening of the four-day hearing in Plymouth yesterday.

A jury heard she had been left in a room with her shoe laces which she used to take her own life on January 28 last year.

Detective sergeant Steve Foale, who initially investigated the incident, said checks on Miss Watts were meant to take place every 15 minutes were not completed.

An observation at 3.45am was skipped before nurses discovered her dead at 4am.

He said that records had been falsified to indicate the check had happened, and the staff member responsible said it was "common practice" to do so.

Ds Foale said "there was no clarity as to how and who completed the checks" on night shifts at the time.

Glenbourne staff, managers and Miss Watts' family, including parents and two sisters, attended the hearing yesterday.

Her father Michael Watts, in a witness statement read at the hearing, said: "I just want to know how this was allowed to happen when she was being checked every 15 minutes in a place of safety."

The inquest heard Miss Watts, of Appledore, near Barnstaple, had suffered from depression after the breakdown of her relationship with her long-term partner Rory when she was 30.

She had worked as a nurse in North Devon District Hospital's emergency department until being suspended and then dismissed over allegations she had a relationship with a patient.

Close friend Michael Harries said she was being "driven down" by a looming Nursing and Midwifery Council misconduct hearing into the matter.

He said she was particularly concerned about public coverage of the case, following previous reports in the press.

The hearing was due to resume on January 24, 2011 but had been postponed until May.

Mr Harries said: "Over the past two years since the complaint, Liz had become more and more depressed. She loved nursing and if that was taken away she didn't know what to do."

Describing her as a "determined woman", he added: "Liz had made up her mind that she wanted to take her own life."

Mr Harries and his wife discovered Miss Watts at her home after the attempted overdose and called an ambulance.

She was taken to North Devon District Hospital and then admitted to Glenbourne acute mental health unit at around 4pm on January 27.

Dr Alexa Farrell, who assessed Miss Watts on her admittance to Glenbourne, said she had appeared depressed but calm and had not actively expressed further intent to commit suicide.

She placed her on 15-minute observations.

Clinical team leader Joe Slater, who had been working that day before handing over to the night shift, appeared as a witness.

He said it was "appropriate" for Miss Watts to be observed every quarter of an hour.

He added that the risk level was "fluid" and staff have a duty to increase checks if a patient becomes more stressed and anxious.

Miss Watts had been allowed to keep her shoe laces as staff had taken a "positive risk" to gain her trust and confidence, said Mr Slater. He also denied that falsifying observation sheets was common practice.

Police dropped their investigation after the Crown Prosecution Service decided there was no case to answer.

An internal investigation by managers led to changes in procedure as well as the dismissal of a mental health nurse and a nursing assistant. The hearing continues.