Page last updated at 19:16 GMT, Wednesday, 24 March 2010

'Low risk' woman from Port Talbot killed herself

Avril Thorne
Avril Thorne's husband said her death could have been avoided

A grandmother took her own life days after a psychiatric medical team at a hospital decided not to admit her as she was at a "low risk" of self harm.

An inquest heard Avril Thorne, 49, of the Sandfields area of Port Talbot, hanged herself in March 2006.

Recording a narrative verdict, Neath Port Talbot coroner Philip Rogers said he was "absolutely satisfied" the system did not work at the time.

The inquest heard emergency outpatient clinic appointments had since changed.

Mr Rogers was told that Mrs Thorne had a history of psychiatric illness, which started a number of years before her death, when she discovered that her daughter was using Class A drugs.

As a result, Mrs Thorne and her husband Paul started looking after their granddaughter, and the inquest was told that she found it stressful and difficult.

On 25 March, Mr Thorne called the out-of-hours GP service, because Mrs Thorne told him she needed help.

A doctor visited their home and assessed her to be "suicidal" and referred her to hospital.

I cannot say whether it was a system operating wrongly, or not adequately at the time, but I do accept the system has fundamentally changed since
Philip Rogers, coroner

She went to Ward F of Neath Port Talbot Hospital - a specialist psychiatric ward for adult patients.

But an assessment by staff nurse Lindsay Martin and the senior doctor on call on the ward Mahibur Rahman found she was at "low to some" risk of self harm.

Dr Rahman discharged her with a three point action plan and referred Mrs Thorne to the out-of-hours psychiatric service, to be monitored over the weekend.

He also referred her to a day hospital, for extra support, and to her consultant psychiatrist for a possible change of medication.

Mrs Thorne had been taking the anti-depressant, Amitriptyline for several months.

But the coroner said the evidence proved "no effective steps" were taken to deal with her case after the 25 March.

Mrs Thorne was found dead at her home five days later.

Mr Rogers said: "I cannot say whether it was a system operating wrongly, or not adequately at the time, but I do accept the system has fundamentally changed since."

In a statement the Abertawe Bro Morgannwg University Health Board said it again wished to apologise and extend condolences to Mrs Thorne's family.

"Devastating loss"

It said following her death a specialist treatment service was set up which was now responsible for the assessment, provision of emergency follow up treatment and liaison with community services.

"Other actions have also been taken to improve our service, including better communication systems between senior clinical staff and the teams looking after patients," it added.

In a statement through his solicitors Mr Thorne said: "Our whole family have been devastated by the loss of Avril.

"I sincerely hope that the NHS does not let this happen to any other family.

"Had Avril received the support she needed then her tragic death would have been avoided.

"Avril was a lovely popular person who is very much missed by all who knew her."



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South Wales Evening Post Suicide woman 'failed' by NHS - 1 hr ago
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