Jury finds neglect contributed to Nottingham woman’s death

Neglect by mental health hospital staff involved in the care of a 22-year-old woman in Nottinghamshire contributed to her death, an inquest jury has found.

Sophie Towle died after suffering a blood clot at Sherwood Oaks Hospital in Mansfield, run by Nottinghamshire Healthcare NHS Foundation Trust, on May 27 2024, a few days after she self-harmed.

The jury found Ms Towle’s care had been “substandard” due to staffing levels and a lack of staff experience, with a reliance on temporary staff who were not familiar with her.

Assistant coroner Alexandra Pountney said she would issue a Prevention of Future Deaths Report to Nottinghamshire Healthcare and Sherwood Forest Hospitals NHS Foundation Trust.

On Friday, the jury at Nottingham Coroner’s Court found a number of failures by the hospitals overseeing her in the months before her death had probably played a part in her passing.

Ms Towle, from Mapperley, in Nottingham, had been in and out of mental health facilities since 2021.

When she was last sectioned in late 2023, she stayed at a mental health facility in Doncaster due to a lack of beds in Nottinghamshire.

She was transferred back to Sherwood Oaks on 24 April 2024.

The jury found that there had been “no clinical rationale” to move her back and agreed with the Rotherham, Doncaster & South Humber NHS Foundation Trust’s admission that co-ordination between themselves and the family regarding her repatriation was poor.

The move back had “destabilised” her and made her upset due to the lack of preparation time for it, the jury found.

When she got there, there was no body mapping or wound care done, no assessment care plan or weight management care plan made, no reassessment of her blood clot risk and an inconsistent care plan with regard to her physical observations.

Two weeks later, on May 12, Ms Towle self-harmed while on 24/7 observations with a healthcare assistant sitting in the doorway watching her.

The jury found that the staff member’s observation was “inadequate and not in accordance with policy”, the Local Democracy Reporting Service said.

Afterward, Ms Towle was taken to King’s Mill Hospital, in Mansfield, which is run by Sherwood Forest Hospitals NHS Trust, and returned to the mental health unit after two days. A wound to her left leg then became painful, leaving her unable to walk and later became infected, the inquest heard.

On May 27, she complained of chest pains and that she felt unwell and later suffered a cardiac arrest.

The jury found Ms Towle’s immobility and her wound becoming infected had likely played a part in the formation of the blood clot that led to her death.

The jury also said inadequate observations on May 12 had “more than minimally contributed” to the immobility and infection.

They agreed with Sherwood Oaks’ admission that it had failed to see the need to assess Ms Towle’s blood clot risk.

Concluding, the jury foreperson told the coroner that as well as the aforementioned contributions to her death, Ms Towle’s hospital transfer, her risk assessments in relation to her access to harmful items, her lack of blood clot risk assessment and the failure to note the fact or significance of her lack of mobility all “probably more than minimally contributed to her death”.

Also listed as a probable contribution was the information sharing between King’s Mill Hospital and Sherwood Oaks regarding Ms Towle’s presentation.

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