Coroner Links Patient’s Death by Suicide to Unchecked Hospital Records

A coroner has stated that an NHS hospital patient died by suicide using tubing she had taken from a medical trolley. Emma Sanders, aged 34, who had a background of mental health issues, was receiving care in a hospital corridor in March 2023 at Royal Bournemouth Hospital because of overcrowding. An inquest revealed that she was discovered unconscious in a toilet and subsequently succumbed to asphyxiation five days afterward. Senior Dorset Coroner Rachael Griffin commented that the patient’s care might have been altered had healthcare professionals reviewed her prior medical history. The coroner’s report indicated that the patient’s medical records, detailing a history of self-harm and personality disorders, were not accessed while she was hospitalized. Ms Griffin stated that these records were not readily accessible during her triage, and no other hospital staff member attended to her prior to the fatal event. She suggested that NHS Dorset and NHS England could take measures to prevent similar future fatalities by resolving problems within the patient records system. The coroner reported that Ms Sanders was admitted to the hospital’s emergency department on 14 March following an overdose. Ms Griffin further noted that she was situated in a hospital corridor, which was being managed by ambulance paramedics because of “capacity pressures.” Within a Prevention of Future Deaths Report, the coroner documented: “At 18.58 hours, when for a very short period of time there were no staff in the corridor, Emma can be seen on the CCTV of the corridor to secrete upon her person a nasal canula with plastic tubing from an equipment trolley.” “At 19.53 hours Emma went to the toilet in the Emergency Department.” “At 20.03 hours, Emma was found in a collapsed and unresponsive condition on the floor of the toilet.” In her narrative conclusion, Ms Griffin stated that it was uncertain if Ms Sanders had intended to end her own life. The hospital has been contacted for a statement, whereas South Western Ambulance Service indicated that the concerns highlighted by the coroner did not pertain to their service. NHS Dorset confirmed it would provide a response to the coroner at a later time. Readers were directed to follow BBC Dorset on Facebook, X (Twitter), or Instagram. The content was copyrighted by BBC in 2024, with all rights reserved. A disclaimer noted that the BBC is not responsible for the content of external sites, and information on its approach to external linking was provided.