Lily Lucas: Ward 'was understaffed' at time of collapse

Lily Lucas was a mental health nurse before she died

The ward manager of a mental health hospital says there were staffing issues the day a patient collapsed.

Lily Lucas, 28, was found unresponsive at the Cygnet Hospital near Weston-super-Mare, Somerset, after drinking excessive amounts of water on 8 September 2022.

Manager Sereiny Dumitru told an inquest on Wednesday she observed Ms Lucas every 15 minutes through her window rather than entering the room.

Ms Lucas died the following day.

An inquest opened on Monday to examine the circumstances of her death and the care she received.

Ms Lucas died while an NHS patient at the privately-run Cygnet in 2022 after being diagnosed with schizophrenia.

On 5 September, she was prescribed antipsychotic drug Clozapine to help manage her symptoms after her mental health had deteriorated the month before.

On 8 September, Ms Lucas drank excessive volumes of water and had collapsed on the floor suffering a seizure and a heart attack, the jury heard.

Staff attempted to resuscitate her for 45 minutes before she was transferred to the Bristol Royal Infirmary for treatment, and subsequently died.

'Observed through window'

Ms Dumitru was the ward manager for Milton Ward at the time of Ms Lucas' admission, and was a witness at Avon Coroner's Court, in Bristol, for the inquest.

As part of being given her first dose of Clozapine, Ms Lucas was observed every 15 minutes to "make sure signs of life is observed", Ms Dumitru told the inquest.

However she admitted she looked through Ms Lucas' window instead of going inside her room.

When Coroner Dr Peter Harrowing asked Ms Dumitru if she agrees she "should have looked in on her and not just through the window?", Ms Dumitru replied: 'yes'.

Ms Dumitru told the jury the ward was "understaffed" that day, and there was only one registered nurse on shift when there should have been two.

She added that the hospital's guidelines state that if someone is drinking "excessive" amounts of water then staff must seek medical advice "as a matter of urgency."

The inquest is expected to last 10 days.

Ms Lucas, from Malmesbury in Wiltshire, was a mental health nurse before she died.