A woman who took her life at a privately-run mental hospital in Leicester, died due to ‘gross neglect’ a jury has concluded.
Samantha Boazman died on October 22 2021 whilst detained under the Mental Health Act at Sturdee Community Hospital, in Leicester.
The inquest into the 54-year-olds’ death has now concluded that she died following gross neglect due to a continuous sequence of shortcomings in her care. Their findings included:
- That there weren’t effective systems in place to keep Samantha safe on 22 October 2021
- That there was a lack of adequate training of staff
- That there was a failure to remove ligature risks from bedrooms
- That Samantha’s risk was not appropriately assessed or managed
- That Samantha was not appropriately observed.
Ms Boazman’s family describe her as a “kind hearted, caring, and generous person who would always put others before herself and who knew how to make others laugh”. She was intelligent and quick-witted and showed amazing courage in the face of her long standing mental ill health.
“My family has been completely devastated by what has happened to my mum. We thought that she was being cared for and was safe but it turns out that the opposite is true,” said Samantha’s daughter, Chantelle Blood.
“I know in my heart that my mum had no intention to end her life that day, and the fact that she was allowed to shows how badly she was failed. Her death was completely preventable and I am glad that the jury recognised this.”
During the inquest, which was held at Leicester City and South Leicestershire Coroner’s Court, the jury heard that on the day of her death Samantha asked for one-to-one’s from a number of staff but it was said that these could not be facilitated due to staffing issues. This was despite this being a recognised mechanism to decrease Samantha’s risk. She also asked for medication to help her feel less anxious but this was not facilitated. She was observed at points to be crying and pacing. A healthcare assistant was sufficiently concerned about Samantha’s presentation that day that she locked Samantha’s bedroom door to ensure that Samantha remained in communal areas. However, after consulting with the ward psychologist, the healthcare assistant was instructed to unlock the door, despite Samantha not having been directly assessed by either the nurse in charge or the psychologist. Instead, Samantha was allowed back into her room and told to practice relaxation techniques. The evidence was that no one reviewed Samantha’s observation levels or undertook a check of her room to ensure that she did not have access to items with which she could harm herself.
Samantha was due to be checked every hour by staff. However, no check was undertaken between approximately 5.30pm and 6.45pm when Samantha was found unconscious, having self-harmed with a specific risk item that remained in her room. The inquest heard that there were delays in staff locating the relevant emergency equipment and in calling an ambulance. Sadly, Samantha died later that day.
The inquest jury heard evidence over 7 days, including in respect of concerns that had been raised both with and by senior managers about the safety and culture of the hospital. Although reliance on agency staff was high, agency staff on the ward on 22 October told the inquest that they had not received an induction from Sturdee Hospital.
Following Samantha’s death, the Care Quality Commission carried out an unannounced inspection of Sturdee Community Hospital. The Commission rated the hospital inadequate, and found not only that the hospital’s ligature risk assessment was incomplete but that there was also no specific mitigation for ligature risks.
Bosses at the hospital, which sits on Runcorn Road, said “significant” improvements had been made at the facility since Samantha’s death. She had been a resident at their for over a year and “they described her as “well liked by staff and other patients.”
“Since Samantha passed away, we have been working with the CQC, and all other parties, to jointly learn any lessons from Samantha’s death, and to focus on the health and well-being of all our patients, which is our number one priority at all times,” they said in a statement.
“We recognise today’s verdict from the coroner, and have already made significant quality improvements at the hospital since Samantha’s death.
“We will now take time to reflect and see if there are any additional steps that we can take to further improve the standard of care we provide to our patients.”
Anyone affected by Samantha’s story, should call Samaritans on 116 123.