Coroner concludes that neglect contributed to the death of Joyce Patterson

Joyce Patterson aged 64 died on 8 November 2017 after being struck by a train, shortly after she absconded from St Helier Hospital.

On 24 October 2018, the Assistant Coroner for Inner West London, Darren Stewart, concluded that Mrs Patterson’s death was contributed to by neglect. Her family were represented at the inquest into her death by medical negligence solicitor Fiona Huddleston.

Mrs Patterson was admitted to St Helier Hospital (Epsom and St Helier University Hospitals NHS Trust) on 2 November 2017 having taken an overdose.  She was treated for the physical effects of the overdose before being transferred to a psychiatric assessment unit at Springfield Hospital (South West London and St George’s Mental Health NHS Trust) on 7 November. 

A mental health assessment could not take place because of the deterioration in her physical condition, which meant that she had to be transported back to St Helier Hospital. She was escorted by a health care assistant (HCA) that evening. The ambulance crew were made aware that she whilst she was not detained under the Mental Health Act, she should not be allowed to leave the hospital.  

She was transferred from the Accident & Emergency department to the Surgical Assessment Unit of St Helier Hospital (she was not due to undergo surgery but there were bed constraints at the hospital) in the early hours of 8 November. The HCA then left, even though Mrs Patterson had not been seen by a member of the psychiatric liaison team (nor was she subsequently).   

At around 11.10am Mrs Patterson attempted to leave the ward. She was told to return to her room by a HCA, who, despite being allocated to Mrs Patterson, was not aware of her mental health history and did not tell anyone what had just occurred.

Some ten minutes later, Mrs Patterson attempted to leave for a second time. She was pursued by the HCA and by her designated nurse. They were unable to persuade her to stop and by the time security arrived Mrs Patterson had left the premises. Police attended the hospital but a short time later Mrs Patterson was reported to have died at St Helier train station.

There were two pre-inquest review hearings which determined the scope of the inquest and the witnesses required to give evidence. The inquest took place over four days, with an adjournment of two weeks before the final day. The coroner accepted that Article 2 of the European Convention on Human Rights was engaged. 

The coroner concluded that there were multiple failures and that the cumulative effect of these failures, constituted a gross failure to deliver basic medical care. 

In particular, he criticised the communication between the two hospitals as to Mrs Patterson’s mental health status and needs, which meant that adequate arrangements to care for those needs were not put in place. 

The coroner also criticised the response of the HCA following the first attempt and the inadequate response of the nursing staff following her second absconding attempt, to prevent Mrs Patterson’s departure. 

The coroner was satisfied that both trusts had made a number of efforts to address the failings. However, he asked for a consolidated report incorporating the matters raised at the inquest. 

Medical negligence solicitor Fiona Huddleston, who represented Mrs Patterson’s family, said: “The family and I welcome the coroner’s conclusion that Joyce’s death was contributed to by neglect and the recognition that there were many failings in Joyce’s care. 

“Whilst it is encouraging that both trusts seem to have listened to the family’s concerns and have taken steps to address the failings, I hope that the new measures proposed will be implemented swiftly and will effectively get to the heart of the issues identified as a result of the inquest.”

Leigh Day instructed Jim Duffy of One Crown Office Row.