Failures led to death of mum-of-five died at Coventry mental health unit
A husband is calling for lessons to be learned after his wife died at Coventry's Caludon Centre.
Teresa Doherty, 43, was found in the bathroom of her room at by a member of staff at the mental health unit about an hour after she had last been seen in February 2016.
Teresa, originally from Ireland but moved to Nuneaton in 2014, was found to have asphyxiated.
An inquest concluded Teresa “died as a result of her own deliberate act” but it was not known “whether she intended that act to cause her death.”
Following the mum-of-five’s death her family instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care under Coventry and Warwickshire Partnership NHS Trust, which runs the centre.
An NHS investigation found, four days before her death, staff had relaxed Teresa’s 15-minute observations to every hour.
The independent investigation also found that there was inadequate ongoing assessment and monitoring of Teresa’s mental health state during her stay, and no documented evidence of one-to-one support or planned therapeutic interventions.
Despite telling doctors "she wouldn’t think twice about ending her life" the day before her death, her observation period was not amended.
An inquest has now heard evidence of how Teresa spent her last few days, which included her revealing to doctors how she was hearing voices and that she did not want to hurt anymore.
Nonetheless, Teresa was kept under the same level of observations and was provided with no therapy or counselling sessions, the hearing was told.
Bina Patel, assistant coroner who sat with an 11-person jury recorded a narrative verdict, concluding Teresa “died as a result of her own deliberate act” but it was not known “whether she intended that act to cause her death.”
