STAFF at a mental health unit failed to step up checks on a Barrow woman who tried to hang herself in the unit, an inquest has found.
The following day, 24-year-old Emma Beth Goulding died at Furness General on April 5 last year having being found unresponsive at the hospital’s Dova inpatient unit where she hanged herself on March 30.
The last day of the week-long inquest on Tuesday heard that Miss Goulding, who worked as a mental health support worker, had a ‘gentle personality’ and ‘loved helping people’.
On April 5, a note was found in her room at the Dova Unit saying: “Don’t blame anyone for what I have done.
“I can’t cope with this mind.”
She was transferred to the Dova Unit from the Hadrian Unit at the Carleton Clinic, Carlisle, on March 25.
Miss Goulding repeatedly made ligatures while staying on Dova. An incident on March 28 led to her being admitted to accident and emergency. In just 12 hours between this day and the following, she made three ligatures.
The style of her ligature also changed on March 29. However, as her attempts increased in frequency and intensity, no moves were made to check on her more regularly.
At the time of her death, she was being observed every 15 minutes.
The inquest heard that multidisciplinary team meetings to review Miss Goulding were not held after each incident of self-harm.
Kirsty Gomersal, area coroner for Cumbria, noted that records kept of incidents were confusing or incomplete. On the day Miss Goulding was found hanged, neither of the two most senior people on the Dova Unit was aware of the change in her ligature method the day before.
Miss Goulding was due to be discharged on March 31, subject to a review, but was not happy about this.
Miss Goulding’s father, James, had previously expressed his belief that ‘neglect’ brought about his daughter’s death.
Miss Gomersal concluded this was not the case but stressed that neglect had a very specific meaning in a coroner’s court and was a rare finding for a coroner to make.
Miss Gomersal concluded that the medical cause of death was 1a) hanging and 2) emotionally unstable personality disorder - which Miss Goulding had been diagnosed as having.
She decided against submitting a report to prevent future death. This was because she was satisfied work - such as changes to staffing levels - had been done by the Lancashire and South Cumbria NHS Foundation Trust to help stop similar tragedies occurring in future.