The death of a 'happy-go-lucky' woman 'would have been avoided' if better procedures were in place at the mental health unit she was being treated at, a jury has concluded.
Claire Louise Morris, 35, died after an act of self-harm in her home in Wythenshawe where she was receiving 24-hour supervision, an inquest at Manchester Coroner's Court heard.
She was sectioned under the mental health act and had been granted leave from Jigsaw Mental Health facility, in Didsbury, when she was found critically injured in her bedroom by staff on December 15, 2020.
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A jury has now found that Ms Morris took her own life but that her tragic death was contributed to by neglect, and outlined a number of failures in her care at the unit in south Manchester.
The court previously heard that Ms Morris had been under the care of Jigsaw Hospital, which was ran by Equilibrium Healthcare, after being diagnosed with unstable personality disorder as a teenager.
During the summer of 2020, she was granted Section 17 leave, which allowed to her return home, where her care plan stated she would be supervised 24 hours a day. But despite her long history of self-harm, jurors were told that nothing had been written in her care plan about how often she should be checked on by staff.
The jury concluded that there was 'a lack of training into the management of self-harm patients' at the time of Ms Morris' death.
During her time under the care of Jigsaw, the court heard that Ms Morris' risk of harming herself fluctuated. But a number of risk-assessments which 'should have been' carried out were not done so in the months leading up to her death.
Jurors listed this as a failure by the facility, and found that more regular risk assessments should have been carried out, especially whenever Ms Morris' condition changed.
On the night of her death, she had been on the phone to her mum, Janet Le Boutillier, who she hadn't seen in months due to the ongoing coronavirus pandemic.
Ms Morris had shared multiple concerns about changes to her nursing team in the lead up to her death, something which was said to have compounded her anxiety.
Speaking about their plans for the upcoming Christmas, Ms Le Boutillier told the hearing: "She said she would not be able to come that year because a member of staff had been rota'd to be with her for Christmas Day who didn't celebrate it.
"She didn't want to upset that staff member by bringing her along. Claire said she'd ask the hospital if anyone else was available but she was told they weren't.
"She loved Christmas and was annoyed at the way things were going. I promised I would phone the hospital the next morning. I had no concerns about her and we had actually arranged to go shopping the next day."
Later that evening, Ms Morris was found seriously injured by a mental health worker following an episode of self-harm, and was rushed to Manchester Royal Infirmary.
She was sadly pronounced dead a short time later. The court heard that she died as a result of a haemorrhage from lacerations to her forearm.
Following Ms Morris' death, Ms Le Boutillier described her daughter as a 'happy-go-lucky' woman who loved singing and cooking, and adored her two cats Angel and Socks.
She told jurors that she believed her daughter wanted to 'live her life' and that self-harm was 'never about dying' for Claire.
"She wanted to become a counsellor to help other people who had been through what she had," Ms Le Boutillier said. "Self-harm was the only way she felt able to calm herself down. She would only do it if she knew there was someone around who could help if she needed them."
Former Hospital manager, Sonya Cunningham, told jurors Ms Morris was the only patient being managed 24/7 at home at the facility at the time. She told the court that when she returned to work from maternity leave in November 2021, Ms Morris voiced that she was unhappy with the way her care was being staffed.
"Claire was unhappy with not knowing who was turning up and it was increasing her anxiety," Ms Cunningham said.
"I wanted Claire to have notice of the rota as I agreed with her that it was distressing that she didn't know who to expect. We agreed to give her as much notice as we could. There was never a time where she didn't have sight of the rota before staff arrived.
"But there was such a high turnover of staff and I was increasingly relying on agencies. It would be 7pm at night and I was trying to find someone who was on her list of agreed staff."
The court heard that Ms Morris' care policy stated that "staff should always know the whereabouts of Claire," but that no prescribed time observations were written.
Ms Cunningham told jurors that despite this not being written down, she would have expected care staff to approach Ms Morris every 15 minutes to check her mood.
"I would expect it to be really clear in the care plan what the minimum times of approaching Claire would be and how it would be recorded," she said.
Jurors heard that a risk assessment of Ms Morris' likelihood of self-harming, which was carried out in August 2020, deemed the current risk as "medium" but historically 'very high.'
When asked by coroner, Zak Golombeck whether another review should have been completed in the run up to December, Ms Cunningham said "yes," adding "I don't know why one wasn't completed."
The jury highlighted further failings in the care provided to Ms Morris, including a lack of effective communication between staff - particularly on the night of her death.
They also found a lack of documented procedures and policies - and training in relation to both of these areas.
Recording a narrative conclusion, they said: "Claire took her own life; However the question of her intent remains unclear. Claire's death was contributed to by neglect."
Ms Morris' family, who were represented by Simon Murray and Natalie Tolley from Stephensons Solicitors, said following the conclusion: "I am satisfied with the outcome of the inquest, I knew that Claire didn't intend to take her own life that night. She never wanted to die."
Ms Tolley added: "The tragic circumstances of this case reflect the fact that staff didn’t pay sufficient attention to Claire’s concerns or anxieties.
"The Jury found that there was a lack of communication between staff members and the hospital responsible for her care which had granted extended home leave on the basis that she would be safe and adequately supervised by staff in her own home.
"Unfortunately, there was a lack of risk assessment, communication or care planning which mean that Claire’s increased risk of self-harming was not noted or communicated. Tragically, the self-harming event on 15 December 2020 lead to Claire’s death."
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