Inquest: 'Unacceptable' errors led to hospital patient's death
An 'unacceptable' catalogue of errors and an inappropriate relationship with an older member of staff lead to the death of a teenager at a specialist hospital for children with mental health disorders, a jury decided today.
Sarah Goldsmith, of Merley in Wimborne, was found dead on the floor of her room at Huntercombe Hospital in Taplow after tying a scarf around her neck on September 8, 2008, the eve of her 17th birthday.
A jury delivered a narrative verdict after hearing six days of evidence at an inquest at Windsor Guildhall which started on Monday last week.
The inquest heard the 16-year-old died of asphyxiation due to ligature strangulation.
But jurors said they believed she had not intended to kill herself and her death was the result of neglect by hospital staff.
On the day she died, she was described by staff as 'in a good mood' and looking forward to spending her birthday with her family.
But at 9.30pm Sarah was found by a healthcare assistant lying on the floor of her room, unresponsive and with a scarf around her neck.
The inquest heard the healthcare assistant did not attempt basic life support and left Sarah unattended while he went to get help because his emergency alarm was broken.
A nurse who came to assist also did not attempt CPR, but did loosen the scarf and found a pulse.
It was not until a second nurse responded that CPR was carried out, which jurors said was of 'poor quality'.
The inquest heard it also took eight minutes before a resuscitation trolley and oxygen cylinder was deployed, which jurors said was due to bad communication between staff.
The verdict also stated an inappropriate relationship with healthcare assistant Anneke Vanzyl may have been a trigger for Sarah to self-harm.
The 33-year-old swapped more than 30 letters with Sarah during her stay as well as exchanging phone numbers.
In one letter Ms Vanzyl, who worked with the teenager in the Thames ward, had threatened to take back a ’friendship’ bracelet she had given her, which Sarah's mum Carol told the inquest would have been 'devastating' to her daughter.
Sarah was also due to move wards as part of her treatment, which Ms Vanzyl said in another letter would 'cause her heart to break'.
Jurors said the relationship was in breach of child protection and hospital governance and 'contributed' to Sarah's death.
Sarah's mum and dad, David, were present as coroner for East Berkshire Peter Bedford read the jury's verdict this afternoon.
He told the hearing two internal investigations were carried out and extra training given to staff at the Huntercombe Lane South hospital shortly after the incident, as a result of Sarah’s death.
He said he would also be writing to the nursing authority in South Africa, where Ms Vanzyl travelled to after quitting her hospital job less than a month after the death, warning them of the concerns raised during the hearing.
He also praised Sarah's parents for their 'courage and dignity'.
Tearful jurors shook hands with the couple as they left the hearing.