UK Inquiry Tracker

Rosalind Flett

PFD Report Historic (No Identified Response) Ref: 2018-0160

Date of Report 24 May 2018

Coroner Selena Lynch

Coroner Area London (South)

Response Deadline est. 2 September 2018

Mental Health related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting thorough searches and potentially missing concealed items.

View full coroner's concerns

In the circumstances it is my statutory to report to you: The MATTER OF CONCERN is a5 follows; The Trust' $ policy on searching was made in accordance with the Mental Health Act 1983 Code of Practice: However, there appeared to be a gap between "an advanced search" which was limited to a pat down of clothing and did not allow for clothing to be removed to underwear, and an "intimate search" which deals with items concealed in a body orifice: Staff were therefore given the impression that could not ask Ms Flett to remove her bra for searching: Since the conclusion of inquest have been informed that the local Trust search policy is to be amended, However, the ambiguity appears to exist in other Trust policies, and therefore make this report in order to the matter to wider attention:

Sent To

Department of Health and Social Care

Response Status

Linked responses 0 of 1

56-Day Deadline 2 Sep 2018

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 21" February 2017 commenced an investigation into the death of Rosalind Flett The investigation concluded at the end of the inquest on 18th April 2018 The cause of Miss Flett' $ death was due to an incised right internal jugular vein. The jury recorded a narrative conclusion: On 11th February 2017 Rosalind Flett was detained under section 2 of the Mental Health Act presenting with emotionally unstable personality disorder and a history of deliberate self harm, at Gresham 1 ward Bethlem Royal Hospital, Beckenham At the time Miss Flett was subject to enhanced arms length observation with thrice daily room and personal searches: However; these measures were not effective in locating any razor blades in spite of five previous incidents of cutting between 27lh January and 8'h February 2017. Sometime between midnight and 0100 whilst standing in the common area with the two nursing staff; Miss Flett ran away the corridor, stopped and a razor blade to make a deep laceration in neck in full view of a third nurse. Miss Flett was transferred to king' s College Hospital, Camberwell; but died shortly thereafter.

Circumstances of the Death

along using her

Ms Flett cut her neck with a razor blade in full view of nursing staff: During her hospital admission she had regularly concealed razor blades in a variety of places, on at least one occasion was known to conceala blade in her bra. It is not known where she concealed the blade that she used to fatally cut her neck:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe vou have the power to take such action: