Ipswich Hospital patient died after 'violent' man pushed her in toilet

Ms Mclaren, who lived in Holland-on-Sea near Clacton, was still living independently and walking to local shops

A woman died after being seriously injured by a fellow patient in hospital toilets, an inquest has heard.

Caryl Mclaren, 89, was knocked to the floor by a man who had a history of violence against staff and patients.

She died five days after the incident at Ipswich Hospital in January 2022.

An inquest heard the patient, referred to as Mr X, lacked capacity but that no formal Mental Health Act assessment was completed for him, despite having been an inpatient for nearly three months.

The coroner was told the ward was short of two healthcare assistants that night and lacking beds for mental health patients.

An adult safeguarding report found that had there been "a formal risk assessment, a formal referral to a dementia specialist, increased staffing and a mental health referral, then on the balance of probabilities the incident could have been prevented".

The inquest heard a formal Mental Health Act assessment was not completed for Mr X

Ms Mclaren, from Holland-on-Sea, Essex, was admitted on New Year's Eve suffering with shortness of breath.

She had several health conditions but was described as very independent and still walked to local shops.

The court heard she was cleared for discharge on 5 January and told her daughter she could not wait to return home.

She was in a toilet cubicle that day when the man forced the door open, knocking her to the floor, leaving her with a fractured wrist, rib and hip.

Ms Mclaren's daughter said her mother was excited to return home on 5 January, before she sustained the injuries

Mr X had advanced end-stage dementia.

Staff described how security were called to his behaviour on five separate occasions and how one nurse raised concerns about his aggression in an incident form in December 2021 after he had punched a healthcare assistant and tried to hit another patient.

The coroner was told he was declared fit for discharge on 29 November, more than a month before the incident, but that staff were unable to find him a care home that would take him quickly, largely because of his challenging behaviour.

Ann Rutland, a deputy chief nurse at the trust, said: "The delay in getting a suitable care placement could have added to the distress of Mr X."

'Many friends'

Mr X's consultant Dr Dan Coates said a formal Mental Health Act assessment was not completed for the patient until after the incident.

The hospital said it had implemented a 12-point improvement plan since Ms Mclaren's death, which included making it clearer to staff as to when patients should receive an assessment.

Ms Mclaren's daughter Lorraine Moss described her as the "most loving, kindest person, who had many friends".

The inquest was adjourned until 6 June.