Mental health case studies:[pull_quote_center]Early morning on a Saturday, Donna was found dead in her bed with a bottle found beside her which was believed to have caused her death.[/pull_quote_center]
Who is Donna?
You may have heard of several people, even the famous people named Donna but our Donna is special and sadly, she was on spotlight during her unexpected, controversial death.
Donna Kirkland is a 30 year old woman from Tamworth, United Kingdom. She is just like any blossoming adult in the peak of her life except that she suffers from depression and frequent self-harming tendencies. On July 30 2013, she was admitted to Caludon Center, Coventry, UK which is a mental facility; she was assigned to the Beechwood Ward, an Acute Admission unit.
Donna needed more attention and after a few weeks was officially detained on the ward 19th of August under Mental Health Act provisions. After about 24 hours, she was then found dead in her bed due to ingestion of drug and alcohol.
Donna is a caregiver in a care facility called Linden Lodge Nursing Home in her area before she got unwell. She was remembered as a very loving and caring person and has brought so much joy and happiness to her family.
It is quite shocking and controversial to have someone die from a facility which is supposed to be the safest place for people sho suffer from mental health issues. Donna was with Caludon Center for under a month and passed away not because of any illness but because of a very preventable cause.
Donna committed suicide and was found in her bed lifeless with a bottle of 500ml energy drink called Lucozade beside her bed. Energy drinks are harmless and does not contain the alcohol that killed her. What’s inside the bottle will totally surprise you. It was actually filled with alcohol based sanitizing gel which was ingested by the patient which led to a bad interaction with her prescribed drug, venlafaxine which was supposed to help her get better.
Donna’s family seeks justice[quote_left]500ml Lucozade bottle found contained 250ml of sanitizing gel.[/quote_left] Donna should have been alive and perhaps, better today. Her death is a huge consequence of the mental facility’s negligence, her death was highly avoidable. Her family had high hopes that she was well looked after and thought that her issues particularly self-harming was well managed and under the staff’s control.
The medicine itself is not the main reason for the patient’s death. When her blood was checked during the post mortem, they found high levels of alcohol deemed fatal which was from the disinfectant. Aside from the bottle of sanitizing gel, a polystyrene cup with at least 1 cm of the same gel was found in her bed. The combination of her prescribed drug and the alcohol suppressed her breathing.
According to Birmingham Mail, Donna’s parents, Susan and Robert Kirkland were truly heartbroken and were desperate for answers about their daughter’s death. The concerned mother said that Donna’s relatives believed that there are “many opportunities through the night where she may have been saved”.
Fact #1: Donna was supposedly under strict monitoring
- Upon arrival, Donna was placed on Level 2 observation that required her to be closely monitored every 15 minutes.
- She was also recommended by a psychiatrist to be placed on a higher observation “with constant eyesight” which is Level 3.
- Several staff members were assigned to monitor Donna in her bedroom the evening before she died but they did not follow the observation guideline and did not even entered her room all throughout the night.
The inquest upon Donna’s death was heard more recently in July last year at Coventry Crown Court. The family was represented by a medical negligence lawyer Tom Fletcher from Irwin Mitchell law firm. A conclusion was given by the jury and is summarized as follows, “The source of the alcohol was the alco-gel (hand sanitizer) found in the ward area and accessible to patients. The alco-gel was consumed in her room, room 1, Beechwood Ward, Caludon Centre, Coventry.”
Donna’s lawyer mentioned that her severe depression was clear and that she was open to everyone talking about her feelings, acknowledging her mistakes and was vocal about wanting to get better. Tom added, “Donna’s family trusted staff at the Caludon Centre to care for her and are frustrated and angry that guidelines do not appear to have been followed to protect their daughter’s safety.”
Fact #2: Patients had unlimited access to hand sanitizing gel which massively contributed to Donna’s death
The matters of concern addressed by the coroner Jason Pegg was mainly emphasized on the alcohol based disinfectant as reflected from the Courts and Tribunals Judiciary publication released. There are 4 major concerns reported as follows:
- Patients having unlimited access to alcohol based hand sanitizing gels
- Patients were allowed to decant the hand sanitizers into cups and other such containers
- Patients are permitted to keep their own supply of the sanitizing gel in their own rooms
- There is a lack of awareness amongst the staff of the alcohol content in the alcohol based disinfectant and dangers of it including the potential for such gels to be ingested
Though the practice of using hand sanitizer is highly recommended for hygienic purposes, allowing patients to dispense and keep their own supply does not make sense. The hand sanitizer is specifically “Purell” which has 66% weight per volume alcohol content and is readily available in the ward and easily accessible by patients.
Fact #3: Caludon Center had other serious issues aside from Donna’s case
- Care Quality Commission– The recent quality report of Care Quality Commission (CQC) which is the independent regulator of all healthcare services in England, indicated substandard care in the Coventry based facility. When asked about the safety of services, CQC answered saying they have found a number of inconsistencies across the services in the center. Other issues included short of staff, outdated risk assessments, incomplete patient records, incompetent staff and unrespected privacy and dignity at times.
- Reviews of patients and their significant others– There are also other service users or family members who have strong opinions about the mental health center. A previous patient with the username Bengy1990 shared her concerns about the management of Beechwood ward where Donna used to be in saying staff are telling unnecessary things and provoking ill patients to do something inappropriate such as trying their cigarettes. Accordingly, they also had sanitary flaws including leaving a patient unwashed and having to wear wet clothes. SheenS who is speaking for her mum’s experience in the ward also felt that her mum and other patients were not well looked after and had several issues of how the ward was run. Fairly enough, comments were answered promptly and issues were said to be addressed. Patient with username rightsawareness mentioned that she was not given her regular medications during her stay in the ward and concluded that her experience was “degrading and severely compromising.”
- Other cases the center was involved in– The law firm Irwin Mitchell had another medical negligence case that is also against Caludon Centre aside from Donna’s which involves a 41 year old woman who hanged herself year 2012 because of the nursing staff failing to observe her whilst she is in the communal bathroom. Not long after Donna’s inquest also came another; 29 year old David Smith which is another case of suicide by hanging himself in his room in the same facility; his family also pointed out inefficiencies of the center that also contributed to David’s demise.
What has been done?
- Following Donna’s case, Coventry’s coroner gave Caludon Center 56 days to submit a report that should contain actions taken, and proposed actions with the timetable for action. Pegg also demanded explanations why there is no action proposed.
- The CQC also mandated a report from the facility covering what actions they would take in response to the essential standards of health and safety not met by Caludon Center particularly on assessment or medical treatment for persons detained under the Mental Health Act 1983.
- UK Department of Health through Secretary of State Dan Poulter MP acknowledged Donna’s case and the need for change in Caludon Center. He also shared important national guidance on Preventing Suicide- A toolkit for mental health services as well as strategy document on Preventing Suicide in England and expected that document to be examined to improve response and management with these kind of incidents in the future.
- Chief executive Rachel Newson of Coventry and Warwickshire Partnership NHS Trust who governs facilities including Caludon Center expressed their sympathy for the Kirkland family and recognized the distress and tragedy the event have caused. She adds, “We work to learn lessons from any incident in our services. Every case is subjected to close investigation before and after a coroner’s report, to ensure we do all we can to strengthen the care we provide.”
- The center was given £1.9 million and was invested to improve services in the mental health unit particularly employing more staff to allow closer observation and quality care for patients.
Caludon Center still operates as of today and are working hard to improve their services especially in the mental health department.
Donna’s severe depression and tendencies to self harm is definitely a huge reason of concern and it entails a lot of attention and care to support her needs. What caused her death is truly a disgrace and a reflection of how she was let down by the healthcare services that she and her family whole heartedly relied on. May Donna rest in peace and may this and other deaths due to medical negligence be an eye opener to institutions and healthcare providers that we may give more importance to our vocation as lives depend on us.
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