Woman killed herself after south London hospital neglect, coroner concludes

"He determined four probable causes of death: her struggles with anxiety and depression, including impulsiveness; a difficult relationship with her ex-partner, including intemperate and excessive texting from him, which called into question her mental health and fitness to be a mother; her justifiable feelings of abuse as a result of his behaviour, and inadequate searching on leaving and entering Rose Ward, a locked 20-bed female-only mental health unit at Queen Mary's hospital in Roehampton."

"The duty to protect someone in a mental health ward from injuring themself with items seems to me to be a fundamental obligation of the ward. The failure to search adequately is so fundamental, it easily passes the Jamieson test [a standard of proof for a finding of neglect in an inquest] She did precisely the thing she should have been guarded against."

"He said Sparman had presented as a voluntary inpatient in Rose Ward, with clear red flags that she was at risk of harming herself. Richmond will also produce a prevention of future deaths report looking at a need for mental health wards to introduce a centralised record of all dangerous items that are on the ward, which he plans to submit to NHS England given its potential national implications."

Michelle Sparman, 48, died on 28 August 2021 from hypoxic brain injury following a suicide attempt four days earlier. The assistant coroner found the death to be suicide while the balance of her mind was disturbed and contributed to by neglect, citing inadequate searches of possessions on entering and leaving Rose Ward, a locked 20-bed female mental health unit. The coroner listed four probable causes: anxiety and depression with impulsiveness; a troubled relationship with an ex-partner including excessive texting; feelings of abuse; and inadequate searching. Perimenopausal, financial and professional problems were noted as possible contributors, and a prevention report will recommend centralised records of dangerous items for mental health wards.

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