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Over the 5 and 6 April 2017 a Coroner’s inquest considered the circumstances around her death.
The inquest heard that Mrs Bell was receiving treatment for depression as a voluntary in-patient at the Cygnet Hospital, on the Skipton road in Harrogate, at the time. Not detained under the Mental Health Act, she had made an agreement to only leave the unit when accompanied.
The Cygnet Hospital works as an independent hospital, helping around 600 in-patients each year. It is an acute hospital and at the lowest end of security for mental health establishments. Typically around 90% of the patients are NHS referrals.
On the 8 June 2016, Victoria tail-gated another person as they left the building. From there she went to the Majestic Hotel and took a room that had been pre-booked the day before. At the time she had made an agreement to only leave the Cygnet by prior agreement and with a chaperone.
The hospital was sufficiently concerned that they started a search in conjunction with North Yorkshire Police. She was found in the Majestic Hotel by staff in a very poorly condition and taken to Harrogate Hospital – she sadly died in the early hours of the following morning.
Cygnet Hospital Manager, Martin Graham explained that since the incident they had made changes to the security arrangements, with each patient, that is allowed to leave independently, being given a card to show the reception staff.
At the inquest, Dr Amal Beaini from the Cygnet, explained the complexity of the treatment and that Victoria Bell was very much working with them. He further explained that being detained under the Mental Health Act was not always a solution that people think it can be, it can in fact cause more problems and be detrimental to treatment. The family present thanked Dr Beaini for the help he had given to Victoria and Dr Beaini commented that he had developed a strong rapport with her.
Mark Stacey, corporate risk manager for Cygnet explained that the incident had been notified the the Care Quality Commission (CQC) and that their own report, that they would share with the family, was overdue. This was of some concern to the family and Mr Stacey would not commit to a time it would be available. Victoria Bell’s family commented that there had been very little development on the report since November 2016.
The Care Quality Commission (CQC) last inspected the Cygnet on 12 December 2016 and published a report at the end of January 2017. It received an overall Good rating, but received a Requiring Improvement rating for Safety, as it had failed to respond to recommendations from a previous inspection on the 13 and 14 June 2016. The recommendations were around meeting requirements for same sex accommodation.
Under the instruction of Assistant Coroner for the West Division in North Yorkshire, Jonathan Heath, the jury of 10 were asked to consider and return on a number of verdicts.
The Jury returned the following verdicts:
- Mrs Victoria Bell took her own life, but it is not established beyond reasonable doubt that she intended to do so
- The level of security whilst in the care of the Cygnet Hospital was not sufficient
- The level of observations whilst in the care of the Cygnet Hospital was not sufficient
A spokesperson for the hospital said: Our thoughts and sympathies are with Ms Bell’s family at this very difficult time.
The well-being of the people we support is our absolute priority. Immediately after this tragic event last summer we carried out a thorough review of security procedures, and have put additional measures in place.
We will carefully review the jury’s conclusion to ensure any additional findings are taken into account.