Note by woman who tried to take her life 'missed'

Elise Walsh died months after being injured trying to take her life in St George's Park Hospital

A note written by a woman before she attempted to take her own life in hospital toilets was "missed", a report has found.

Elise Walsh died in June 2023, 16 months after suffering a brain injury during the attempt at St George's Park Hospital in Morpeth.

In a prevention of future deaths report, Northumberland coroner Andrew Hetherington said Ms Walsh had written a "note of intent" but that it was not referred to health chiefs.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust said it was undertaking a review to address the coroner's concerns.

In his report, Mr Hetherington said Ms Walsh had voiced her anger at the trust's crisis team and requested a complaints form after a routine psychiatric appointment.

As a result of the attempt on 12 February, Ms Walsh was left "debilitated, bedbound and non-verbal" and had to be fed via a tube.

'Concerned'

She died the following June from pneumonia.

Mr Hetherington said the note left was not referred to in witness statements or in the serious incident investigation and that Ms Walsh's family were not aware of its existence.

Ms Walsh had a history of self-harm and in January 2022 approached the police and said she had suicidal thoughts.

She was referred to the crisis team and voluntarily attended appointments at the hospital.

However, on 12 February 2022, she appeared "agitated" after her appointment and refused to get in to a booked taxi before requesting the complaint form, the report said.

The coroner said he had been told complaint forms were sent to another hospital without staff reading them, however, he concluded they were read by administrative and clinical workers on site.

Mr Hetherington said he was concerned that important information from a patient could be "missed" leading to a "significant delay in administering treatment or intervention".

A spokesperson for the trust said its thoughts were with Ms Walsh's family at a "difficult time."

"We take all concerns very seriously and are undertaking a review into our processes to address those highlighted by the coroner," a statement added.

"We plan to write a report for the coroner within the timescales provided."