Kirsty Thain inquest: Inadequate care contributed to midwife's death

Kirsty Thain had been detained under the Mental Health Act

The death of a midwife, who choked while on a psychiatric ward, was in part due to inadequate care relating to food, an inquest has found.

Kirsty Thain, 36, died after choking on a chip butty while at Kendray Hospital in Barnsley in July 2020.

She had been regarded as high risk due to previous attempts to take her own life, many involving choking.

Returning a verdict of suicide, an inquest jury found there was also "inadequate assessment around food".

South West Yorkshire Partnership NHS Foundation Trust said: "We are very sorry that, in this instance, our care fell short of our usual standards and expectations."

It said that after Ms Thain's death it conducted "a thorough investigation" and had identified ways to improve its care.

The four-day inquest at Sheffield's Medico-Legal Centre heard how Mrs Thain had been voluntarily admitted to Fieldhead Hospital at the start of 2019.

She was detained under the Mental Health Act and was transferred to Kendray Hospital in October 2019 where she died on the 9 July 2020.

The inquest heard how Mrs Thain, from Wakefield, had told staff she wanted to take her own life and there had been more than 50 incidents of self-harm since she had been admitted to hospital.

On the day of her death, some of her food, including a banana, was cut up to minimise that risk.

However, the chip sandwich was only cut in half, the inquest heard.

Giving evidence, staff nurse Gemma Martin said she was unaware on the day of Mrs Thain's death that her notes included how food should be cut into smaller pieces for her.

The inquest was held at the Medico-Legal Centre in Sheffield

The jury returned a verdict of suicide and said Mrs Thain "demonstrated a high risk of deliberate self-harm".

They said there was no care plan around food and there was "inadequate assessment, communication and mitigation on the ward relating to food".

Assistant coroner Alexandra Pountney said she had been "quite impressed" with the measures South West Yorkshire Partnership NHS Foundation Trust had implemented following Mrs Thain's death.

She said because of this there was no need to prepare a Prevention of Future Deaths report.

The trust added: "When Kirsty died four years ago we carried out a thorough and immediate investigation and identified ways to improve our care and enhance our service delivery.

"As a learning trust we continue to work to ensure the services we deliver are the best they can be."

Mrs Thain, who had worked as a midwife at Leeds General Infirmary, was described by her family as "a social butterfly", who was the "life of the party" and "lived life to the fullest".

In a statement outside court, her family said some of the evidence at times "has been harrowing".

"[We] have learnt how risk assessments and care plans relating to Kirsty's inpatient care could have been more robust, which may have prevented the incident that caused Kirsty to die," they said.

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