Sussex Partnership NHS Foundation Trust offers ‘sincere condolences’ to family of woman who died after inquest reveals failures

An inquest into the death of Nicolette Elizabeth McCarthy, 46, who had bipolar disorder, began on Monday, November 4, 2024, at Muriel Matters House, Hastings.

It was heard before jurors and Assistant Coroner Michael Spencer.

Nicolette was a midwifery matron at Crowborough Birthing Centre. She had been a patient at the Trusts’ Woodlands Centre, St Leonards-on-Sea, when she went missing and was later found dead on September 19, 2023.

The conclusion of the Coroner, on the Record of Inquest, said: “Nicolette Elizabeth McCarthy died as a result of suicide due to her acute mental ill health and a series of contributory factors. There were a series of failures in the systems and procedures which should have guaranteed her safety.”

The Record of Inquest said there were ‘unacceptable delays in taking appropriate action’ after Nicolette went missing. It said: “The Trust’s adherence to robust note keeping/updating appears to have been lax and retrospective at times. It is possible that on 19th September 2023, had staff taken prompt action there would have been opportunities by which Nicolette’s death could have been avoided.”

The ROI added that there was an ‘insufficient adherence to recording patient login time in the procedure on the S17 leave sheet’.

East Sussex family want answers from inquest after mother-of-five dies

Before the inquest Irwin Mitchell, representing the family, said Nicolette had been granted permission to leave the ward for ‘a 15-minute unescorted smoking break’ on September 19. They said her body was discovered shortly after 20 miles away.

The ROI said Nicolette had been detained under the Mental Health Act. It said Nicolette’s family attended the ward round discussion on September 18, adding that there is ‘no evidence that confirmation of escorted or unescorted leave was delivered to them’.

The ROI said: “Any ambiguity could have been avoided if Trust procedures had been followed, written confirmation of the S17 decision provided and acknowledged by the family. It was appropriate to grant in principle unescorted S17 leave but not implement it until written confirmation was provided to the family and the risk assessment updated. Nicolette should not have been required to leave unit grounds.”

The ROI continued: “As per the Trust’s concession, the Trust did not take immediate action, aligned to Nicolette’s individual clinical risk, when Nicolette did not return to the ward, following her 15 minutes leave (starting at 14:37) on 19 September 2023.”

The ROI said a failure to mark Nicolette as AWOL instead of ‘on leave’ added to the confusion. It said: “Although staffing levels were low and incidents on 19th September 2023 further impacted staff availability, there was a failure to take steps as outlined in Trust policies following identification of Nicolette’s absence.”

A spokesperson for Sussex Partnership NHS Foundation Trust said: “We offer our sincere condolences to the family of Nicolette McCarthy. We apologise unreservedly for the delay in our response when Nicolette went missing and wholly accept the Jury's findings that there were failures in our processes, procedures and record keeping. We are committed to listening and improving the care we provide and have already introduced greater safeguards to respond to the needs of patients requesting breaks from our inpatient units.”

Thomas Riis-Bristow, medical negligence lawyer at Irwin Mitchell, said Nicolette’s family are ‘heartbroken’. He said: “Sadly, the inquest has vindicated the family’s concerns with investigations identifying worrying issues in Nicolette’s care.”

He continued: “While nothing can make up for Nicolette’s death, we’re pleased that we’ve at least been able to provide her family with the answers they deserve. However, Nicolette’s death is a stark reminder of the need to ensure the highest standards of patient safety are upheld at all times.”

Nicolette’s husband Scott, 49 said Nicolette was a loving and caring person who always put her family first. He said: “Not only was Nicolette devoted to her family but also the NHS. She spent years helping and caring for others and it’s difficult not to think that when she needed help the most she was badly let down.”

A Samaritans spokesperson said: “Whatever you are going through, you don’t have to face it alone. Call Samaritans for free on 116 123, email [email protected] or visit www.samaritans.org for more information.”