Psychiatrist who cut monitoring frequency of patient before death 'didn't know 22-year-old was at A&E with self-harm injuries two days before'

A psychiatrist who reduced the amount an in-patient at a mental health unit was being observed in the week before her death has said he was not aware she was admitted to A&E with self harm related injuries less than 48 hours earlier.

Cerys Lupton-Jones was just 22 when she died following a stay of around six months in Park House, a mental health unit based at North Manchester General Hospital. The unit is operated by Greater Manchester Mental Health NHS Trust.

Cerys was found ‘unconscious’ on Elm ward on the afternoon of May 13, 2022. She died five days later. Cerys died with her family and friends at her side on May 18, after it became clear she would not regain consciousness and her life support was turned off, her family told the M.E.N.

A pre-inquest review into her death in October heard Cerys was involved in a ‘ligature event’ the previous day, May 12, and another at around 2.30pm on May 13.She was then found unconscious after another incident involving a ligature half an hour later, at around 3pm.

On Tuesday (May 7) an inquest at Manchester Coroner’s court, nearly two years after Cerys’ death, heard the 22-year-old had suffered ‘a number of deliberate self harm incidents’ and was detained under section 3 of the mental health act for treatment.

During her stay at Elm Ward in early May she was under the care of consultant psychologist Dr Bhandary. The inquest heard Elm Ward is a standard ward and not a psychiatric intensive care unit.

Giving evidence on the first day of the inquest on Tuesday, Dr Bhandary said there was ‘no psychiatric rationale’ to place Cerys in a psychiatric intensive care unit but said that over the months of April and May 2022 Cery’s risk of deliberate self harm was ‘high’.

The inquest heard that on May 6 Cerys returned to Elm Ward after taking an overdose on April 28 that led to her being admitted to A&E and spending a night there. On her return to Park House she was initially admitted to Poplar Ward as her bed on Elm Ward was no longer available.

Two days after her return to Elm Ward on May 8 Cerys tied a ligature in one of the bathrooms.Fortunately staff were able to intervene. In a written statement submitted to the court, Dr Bhandary said that following the incident Cerys ‘realised she had found a way to commit suicide which made her want to do it more’.

Notes from a mental state examination following the incident, that included an interview with Cerys, were read in part to the court. According to the notes during the interview Cerys told Dr Bhandary she felt ‘hopeless and suicidal’, had ‘vivid suicidal thoughts’ and ‘could not get the thoughts out of her head’.

Following the ligature incident Cerys was placed on one to one observation, meaning a member of staff was with her at all times.

Less than 48 hours her prescribed observations were however reduced to one every 15 minutes by Dr Bhandary.

The inquest heard that on May 10 Dr Bhandary reviewed Cerys at a planned multi-disciplinary team meeting (MDT) meeting. He told the inquest Cerys had ‘struggled’ with the one-to-one observations saying that they would make her ‘more distressed’ and that following a discussion with her a decision was made to reduce them at her request.

Dr Bhandary said patients can find one-to-one observations ‘restrictive and distressing’ and that a ‘clinical judgement’ is made on whether to decrease them. He added: “Cerys made it clear she was willing to work with us and would keep herself safe.”

Dr Bhandary said that although Cerys had suicidal thoughts there was ‘no intent or plan’, adding: “She was clear she wanted to get better and move on with her life.”

He said rather than being an attempt to take her own life the ligature incidents were her way of ‘communicating distress’ and a ‘coping mechanism’.

When asked by coroner Zak Golombeck what his understanding was of the ‘direction of travel’ Cerys’ care was taking, Dr Bhandary said Cerys was ‘always very clear that she wanted to get better’ and move into supported accommodation.

He added that in hospital her self harm was ‘escalating’ and she wanted to be in the community and was ‘looking forward to her future’.

When later asked by Amy Rollings, the lawyer representing Cerys’ family, whether Cerys asking to reduce her observations may have been a way for her to secure more freedom to self harm, he replied: “Not with Cerys no.”

Just a matter of hours after Cerys’ prescribed observations were reduced there was another ligature incident. Cerys was taken to A&E with a head injury and was discharged later that evening at 10.30pm. She was placed on one-to-one observation by nursing staff at Park House but they were again reduced by Dr Bhandary.

Dr Bhandary said he was not told about the ligature incident on May 10 when he came into work on May 11 and assumed Cerys was continuing on observations every 15 minutes.

He told the inquest he did not check Cerys’ progress notes that mentioned the incident as he expected that he would be told about any incidents by ward staff. Dr Bhandary added that had he been told about the May 10 incident he would have set up another MDT meeting on May 11 and kept Cerys on one to one observation until the meeting.

Dr Papadopolus, who was working as a trainee psychiatrist under Dr Bhandary at Elm Ward at the time Cerys was there in May, then gave evidence.

He said Cerys was at a ‘high risk’ of deliberate self harm in April and May 2022 and that there was a ‘risk of accidental suicide given the means of self harm’.

Dr Papadopolus said he regarded the ligature incidents as a way of ‘managing distress’ and for Cerys to ‘reset her thoughts’ rather than attempts to take her own life. He added that her risk of suicide was ‘medium’ and would fluctuate.

He said he too was not made aware of the ligature incident on May 10 and that he next saw Cerys on May 13 for a ward round but did not notice any signs of ligature. He said it was his understanding there had not been any incidents since the last time he saw her.

Dr Papadopolus said he did not check Cerys’ progress notes, saying: “You rely on nursing staff to give you a handover regarding incidents.”

The inquest heard that the progress notes referenced that Cerys had made an attempt to take her life and she had reported that there were times when ligature was the only thing that could provide her relief from her overwhelm. The notes also described Cerys as having ‘bloodshot eyes’ following a ligature incident and a mark.

The inquest then heard that the last thing Dr Bhandary asked Cerys to do following their meeting on May 10 was to write a letter detailing her feelings. Within the letter Cerys wrote she was in a ‘constant state of panic’, felt ‘constantly overwhelmed’ and that her panic was causing 90 per cent of her ligatures.

Dr Papadopolus said he read the letter at the start of his shift on May 13 and changed Cerys’ medication as a result. She was not put back on one-to-one observations.

Proceeding