Inquest Concludes Hospital Failures Contributed to Patient’s Death

A jury investigating the death of a 20-year-old woman concluded that staff inadequately supervised and secured a room, leading to her death. The inquest determined that Jessica Powell, of Yeovil, Somerset, who died after becoming trapped in a therapy room window in an apparent escape attempt from Summerlands Hospital in August 2020, did not intend to end her own life. Jane Yeandle, the service group director for mental health at Somerset NHS Foundation Trust, stated: “We are very sorry that she died as a result of an incident in our care.” Miss Powell had been awaiting specialist treatment and had a history of attempting to abscond. Her father, John Powell, informed the BBC: “It was just an error of judgement and unfortunately for Jess she just took her chance and that was the way it happened.” The inquest determined that the hospital’s shortcomings involved a faulty alarm system that was not updated, which directed staff to an incorrect location. Furthermore, personnel were unable to free Miss Powell due to insufficient access points from both exterior and interior doors. The jury’s ruling stated that staff “failed to adequately supervise and secure the therapy room which was fitted with windows that Miss Powell, a frequent absconder, might reasonably believe she could escape through”. Miss Powell had been under the care of mental health services since she was 16 years old. She was receiving treatment for emotionally unstable personality disorder (EUPD) prior to being sectioned in October 2019. During the inquest, held in Wells, the jury was informed that she had been admitted to the Psychiatric Intensive Care Unit in January 2020 due to an increasing frequency of self-harm. In May 2020, she managed to escape from the ward via a dining room window, even though the window was equipped with restrictors intended to prevent such an occurrence. On the evening of 19 August, a search was initiated by staff after she did not collect her medication around 22:00 BST. She was found between 22:30 and 22:40, with her lower body protruding from a narrow gap, no wider than 10cm. The inquest determined that the room had been left unlocked, notwithstanding her prior escape attempts. Three days later, she passed away at Yeovil District Hospital. Her primary cause of death was identified as an hypoxic brain injury, resulting from a deprivation of oxygen. Mr Powell remarked that “when she got an idea into her head it was very hard to remove it.” He further stated, “When It came to living in the real world, she was just so vulnerable – all she wanted to do was make friends.” Her sister, Lucy, commented: “She was a very loving auntie, and I miss her every day.” Ms Yeandle stated that subsequent to Miss Powell’s death, the trust has “commissioned an independent report to look at her care and treatment, the layout of the ward, and to answer her family’s questions.” She added, “Our thoughts are with Jessica’s family and loved ones. She was loved and intelligent and we are very sorry.” “We look forward to all of the report’s recommendations but will now look closely at the inquest’s conclusion to see if there are further actions we need to take,” she concluded.