'How on earth did she get that?': NHS still clueless after mum took her own life in 'secure' hospital

Michelle and her children Max and Sam
-Credit:Roger Stephens


A coroner has demanded to know 'how on earth' a mum got hold of a ligature used to take her own life after the ward manager conceded the 'conundrum' remains unsolved four years later. Michelle Sparman, 48, from Battersea, South West London, died in hospital four days after attempting suicide at Queen Mary’s Hospital in Roehampton, where she had been admitted as a voluntary inpatient in August 2021.

The personal trainer and part-time call dispatcher for the Metropolitan Police had been rushed to Chelsea and Westminster Hospital for an overdose and self-harm on August 21, less than 24 hours after she was seen by her GP for mental health issues. Michelle was then transferred to a locked ward at St Mary’s, where during a visit from her ex, Roger Stephens, the mum-of-two tried running into the road and hurting herself in a variety of ways – something Mr Stephens said he disclosed to nurses immediately.

Michelle, who was meant to be searched and never had approval to have the item, continued to be on 15-minute observations until was found in the showers on Rose Ward at St Mary’s with the ligature around her neck on August 24. It caused injuries that would prove fatal, and after a final visit from her boys on August 27, Michelle’s life support was switched off at Kingston Hospital on August 28.

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On Tuesday, January 28, Inner West London Coroner’s Court heard there had never been a formal investigation into how the item was acquired or disciplinary action against any members of staff. Legal counsel Jennifer MacLeod, acting for the family, indicated she would take instruction on whether they would be seeking a finding of 'neglect' ahead of the coroner's conclusion later this week.

The ligature conundrum

Rose Ward was located at Queen Mary's Hospital in Roehampton in August 2021 -Credit:Google
Rose Ward was located at Queen Mary's Hospital in Roehampton in August 2021 -Credit:Google

A psychiatrist who treated Michelle, Dr Rose Mbah-Maduabueke, said she believed there was a blanket ban on such items in the ward, and that all searches were done in an airlock before gaining entry. However the nurse in charge of the ward, Meredith Kuleshnyk, told the court some items that are usually banned could be kept through a written risk assessment.

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Coroner Bernard Richmond KC picked up on the contradiction and asked Ms Kuleshnyk to help him solve the ‘conundrum’ of how the ligature ended up on the ward. The ward manager explained there was no record of Michelle being allowed such an item, ever having one, or anyone else on the ward having one. “I do not know how [it] got onto the ward,” she said.

After grilling Ms Kuleshnyk on the policy and the practices of her staff, Mr Richmond said: “Is there not the potential that someone has committed a very grave error? You did not bring [it] in. You know it was not you. You have got to consider the possibility one member of your staff has somehow allowed [it] in that should not have been there.”

Ms Kuleshnyk eventually agreed, but conceded there had been no formal investigation or disciplinary procedure as a result. The middle manager then suggested the ligature may have been ‘missed' under a baggy jumper or hoodie, but insisted there had been learning, ‘more vigilance’, and better training around searches since Michelle’s death.

Another nurse, Catherine Mhlanga, said she or one of her colleagues would have done something if she knew Michelle had such an item, or if Mr Stephens had told her about Michelle’s self-harm incidents during the visit outside the hospital. “There’s no way I would have forgotten to record such important information like that,” Ms Mhlanga added.

Mr Stephens said he brought a bag containing Michelle’s jeans on August 22, and that staff had looked through the bag before handing it to her on Rose Ward. “The logs and the searches never happened in front of me other than a look through the bag,” he added.

'Emotional abuse'

Roger says Michelle 'couldn't be more happy and beautiful' when she fell pregnant with their children
Michelle Sparman was a personal trainer and part-time call dispatcher for the Met Police -Credit:Roger Stephens

In her evidence concerning Michelle's mental state, Dr Mbah-Maduabueke said Michelle told her about her break-up – including alleged lies by Mr Stephens, ‘angry’ messages, and ‘I love you’ messages – but did not disclose any allegations of physical violence. The doctor told the court she characterised Michelle’s own description of her relationship as ‘emotional abuse’.

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Describing what Michelle told her, the doctor said: “She reported feeling worried about failing her boys and failing her partner about not being what she wanted him to be. He had been cuddling her, but had not initiated anything sexual. He wanted them to get back together, but she wanted to separate.

“She said her ex was doing a good job with the boys right now so it’s difficult to say anything negative. But she said he can be manipulative. He would send messages like ‘You have ruined my life’ because she ended the relationship and he was unemployed.”

Asked how knowledge of Michelle’s previous concerns about her partner, shared during a Talk Wandsworth therapy session, might have affected her views, Dr Mbah-Maduabueke said: “Everything depends. She reported that a few months earlier, but now her partner is helping her, she says she does not want to say anything negative. I’m not a police officer. I do not police these patients. I can’t tell her you must stop contact with him.”

‘She had tried to leave before’

On Monday, January 27, Michelle’s brother Shaun Case told the court Michelle ended her relationship with Mr Stephens – after he allegedly lied about the location of a work trip and meeting with another woman – but was ‘bullied’ into staying with him he 'bombarded' her with texts about her mental capacity, fitness to be a mother, and the effect on Mr Stephens.

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Mr Case said he was ‘shocked’ by the messages and remembered Michelle speaking about anxiety, sleeplessness, and her fear of ‘unpredictable’ Mr Stephens turning up at her flat.

Recalling a conversation with his sister in November 2020, Mr Case said she told him Mr Stephens had said he would commit suicide because he 'could not live without her' and she was feeling responsible. He also said she reported Mr Stephens 'screaming and shouting' at her front door, with secret recordings to prove it.

“What was wrong with what he was doing was knowing that Michelle was affected by his behaviour. Michelle had already said she had tried to leave before, and because of his behaviour, she had decided to stay,” said Mr Case.

Mr Case also claimed family mediation ‘had not gone well’, and recalled Michelle telling him there was ‘screaming and shouting’ from Mr Stephens about her being a ‘bad mother’, ‘uncaring’, and ‘selfish’, plus a reference to her life insurance policy.

Remembering a 'wobble' around Christmas 2020, Mr Case said: "She called me distressed and upset and she just said she's struggling to cope with Roger's behaviour and she thinks it's probably easier to just get back with him."

Anthea White said she also noticed changes in her sister's behaviour, including last-minute cancellations, comments about Mr Stephens’ ‘relentless’ messages, and that she was 'dreading' seeing Mr Stephens more during the summer holidays.

Commenting on a time she said she heard Mr Stephens shouting on the phone, Ms White said: “It made me feel really anxious hearing him. It really stressed her out.”

'I was collateral damage'

Giving his evidence, Mr Stephens conceded sending too many texts, making Michelle’s life ‘very difficult’, and putting stress on her, but also insisted he ‘absolutely’ loved her and blamed her mental health issues on hormone changes.

“It’s important to know that for 27 years, we have been in a relationship. Both of us had ups and downs, but her mental health issues after the birth of [her son], that was not my doing. That was her hormones, perimenopause,” said Mr Stephens.

“I was collateral damage when her mental health was too bad. I could not cope with it. I know my texting was not good. Losing my family and my love. Hindsight is a terrible thing. She was doing it to me. Half of the texts, if you read them. The fundamental thing is I always loved her.”

Under questioning from Ms MacLeod, Mr Stephens conceded it would have been better if he stopped sending the messages and acknowledged he had ignored Michelle's requests to stop. However, he remained bullish about his role in her mental health, later adding: “I was not a monster. I was Father Christmas.”

A GP, who saw Michelle and prescribed sleeping pills a day before she self-harmed, recalled she said her mental health had improved and that she had no plans to hurt herself. Dr Samuel Lee said any signs of domestic abuse were not something he ‘particularly picked up on’ and that he observed a ‘quite warm’ relationship between Michelle and Mr Stephens at the appointment.

Ahead of the inquest, Southall Black Sisters, a domestic abuse advocacy non-profit, said Michelle's family have concerns about alleged domestic abuse in the years leading to her death, and that they will invite the Coroner to consider how the behaviour of her ex-partner impacted on Michelle’s mental health.

Got a tip, a court date, or some gossip? Please email callum.cuddeford@reachplc.com or WhatsApp 07580255582.

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