A vulnerable woman with a mental illness died after ‘absconding’ from a supermarket while on ‘supervised leave’ from a hospital with a care worker.
Hayley Cowan, 29, who was being held under the Mental Health Act at Prestwich Hospital, ran away as both she and the care worker she was with went to the toilet in the nearby Tesco store in Prestwich, Bury. She was found dead the next day “after using drugs at a friend’s house she had gone to,” a report said.
A coroner has subsequently said there has been a ‘lack of consistency’ over the definition of ‘supervised leave’ and ‘supervised leave’. As a result, she has written to the Department of Health and Social Care and Home Secretary James Cleverly to ‘prevent future deaths’.
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Mrs Cowan died on June 4, 2022. An inquest jury at Rochdale Coroner’s Court ruled she died as a result of misadventure, with a medical cause of death confirmed as an ‘adverse reaction arising from mixed drug use’.
The now published Prevention of Future Deaths report, by Manchester North coroner Joanne Kearsley, says Ms Cowan had been detained under the Mental Health Act since July 2021 after setting fire to her flat. She is described as having a “long history of involvement with the mental health system” and having previously been detained.
Ms Cowan was diagnosed with paranoid schizophrenia and ADHD. She was described in the report as a risk to herself and others and also had a “long history of illicit drug use.”
She was held in the Edenfield unit at Prestwich Hospital, run by the Greater Manchester Mental Health and Social Care Trust. It is the largest provider of mental health care in the region and has been under scrutiny for months after a large number of shortcomings in vulnerable patients came to light.
After responding well to antipsychotic medication, the report reveals Ms Cowan was placed on leave. “There were times when her leave was supervised and over time it was sometimes done unaccompanied,” Ms Kearsley said.
‘Her leave also extended from staying on the hospital grounds to the local Tesco store across the road and sometimes to the local village. There had been at least two occasions when Hayley had absconded and run away from the staff with her. She had used drugs. and then returned to the hospital.
“It was believed at all times that she was at risk of absconding, which was motivated by her urge to use drugs. On June 3, 2022, Hayley was placed on supported leave with a support worker to the local Tesco store. Both Hayley and the emergency worker had to go to the toilet and during this time Hayley was found deceased the next day, after taking drugs at a friend’s house she had gone to.
“There were no guidelines for staff on what to do if they needed to use the bathroom. Guidelines were given on what to do if a patient needed to use the bathroom and was therefore out of sight.”
The coroner said the evidence at the inquest ‘revealed matters of concern’. Ms Kearsley added in the report: “The court heard evidence about the lack of consistency and clarity for mental health services in understanding and defining how section 17 leave should be implemented.
“Guidelines on whether a patient should remain in the ‘eye-line’ or at a ‘reasonable distance’ are inconsistent. The Mental Health Act codes of practice, Ministry of Justice guidance to forensic healthcare providers and trust policies are inconsistent. This is particularly the case when considering whether a patient should be within ‘eyeline’ or ‘reasonable distance’ during leave.
“There is also no guidance on how trusts instruct staff on practical matters such as what to do if the staff member needs to use the toilet while out with a patient.”
The Department of Health and Social Care has expressed its condolences to Ms Cowan’s family and friends and said it responds to and learns from every report into the prevention of future deaths. The MEN has asked the Greater Manchester Mental Health and Social Care Trust for comment.