A coroner will write to hospital bosses over his concerns about a ward where a talented singer was found hanging following a serious mental health episode.
Mina Topley-Bird, the 24-year-old daughter of trip hop pioneer Tricky and singer Martina Topley-Bird, was found hanging in Elm Ward at West Park Hospital, Darlington, in May 2019.
A four-day inquest in Durham into her death led coroner James Thompson to say he will make two so-called prevention of future death reports, one of which will raise concerns that a safety check has not been completed to look at reducing the risk of patients self-harming on the ward.
Ms Topley-Bird had performed with her band, the 404, in Newcastle on May 5 and was travelling back to her home in south London when she became agitated.
She got off the train at Darlington and needed hospital treatment while experiencing a psychotic episode.
She was assessed at accident and emergency and was transferred to a secure ward at West Park, where she received treatment voluntarily, and was not detained under the Mental Health Act.
A hour before she was found hanging, on May 8, she was frustrated at not being able to be transferred to a hospital in London and said “I might as well kill myself” and this was thought to have been a flippant comment.
In part of a lengthy narrative verdict, jurors found that there had been a failure to appreciate she was at increased risk of suicide following that comment; there was a failure to take precautions against that increased risk and that the absence of the singer’s historic medical records at the unit meant staff were not aware of her impulsive behaviour.
Mr Thompson said he will now write to the Health Secretary about formalising how mental health patients are transferred between hospitals, saying current arrangements were ad hoc.
I am not entirely convinced that the physical environment has been surveyed for risk of self-harmJames Thompson
And he will write to the chief executive of the Tees, Esk and Wear Valley NHS Hospitals Trust, which runs West Park, to raise a number of issues, some of which concerned how medical notes from other trusts were shared.
And Mr Thompson said: “I am not entirely convinced that the physical environment has been surveyed for risk of self-harm, such as ligature points.”
Ms Topley-Bird’s aunt and grandmother followed the proceedings remotely, among other relatives, and the coroner sent his condolences to the family, saying they had heard evidence which was “distressing and disconcerting”.
Mr Thompson also paid tribute to the singer-songwriter who was a “talented young woman” and who had “fought valiantly” against her mental illness.
Elizabeth Moody, director of nursing at Tees, Esk and Wear Valleys NHS Foundation Trust, said: “Our thoughts remain with Mina’s family and friends during this very difficult time.
“With the South London and Maudsley NHS Foundation Trust, we undertook a comprehensive review of Mina’s care following her death in 2019, and took action to mitigate future risk and improve the safety and care of our service users. Trust witnesses gave detailed evidence during the inquest regarding the learning outcomes and the measures we have taken.
“We will immediately assess the coroner’s recommendations and continue to implement further improvements to our services to ensure the safe care of our service users.
“The trust would also support a national policy relating to the transfer of out-of-area patients, as highlighted by the coroner.”