Pamela Bailey
PFD Report
Historic (No Identified Response)
Ref: 2014-0040
Coroner's Concerns (AI summary)
Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.
View full coroner's concerns
have seen an action plan; which am informed was created after the report of the Serious Incident Panel in September. It was last updated on the gth January 2014. _ Door security no final decision has been made yet; but my understanding is that it is proposed to introduce a system for all secure wards, whereby there is a dual system involving code and swipe card. Is this the proposed alternative to the current system , and bearing in mind it is now about ten months since this incident when is it proposed such action should be taken? (2) On Saturday March 2013 the staffing on Hawthorn Ward was only three; whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement; although it had not involved contacting senior management; having failed to obtain a replacement by contacting either existing staff or flexi staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case, It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place_ (3) There was no photograph available; of Mrs Bailey, to the Police when she disappeared: This clearly raises a number of difficult issues, as to the obtaining and retaining of a photograph_ What decisions have been made in this regard?
Sent To
- Sheffield Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
24 Mar 2014
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 4th April 2013 commenced an investigation into the death of Pamela Margaret Bailey, aged 68. The investigation concluded at the end of the inquest on 13th January 2014 The narrative conclusion was: That Pamela Margaret was admitted to Hawthorn Ward, Northern General Hospital, Sheffield on 30t September 2012, and detained under the Mental Health Act 1983. She became an informal patient in December 2012 and during February March 2013 both escorted and unescorted leave took place: On March 2013 at approximately 1830 hours she left the ward without observed. Her movements after that time are not known: She was found deceased on March 2013 at a secluded location at Ladybower , Derbyshire It is not clear what her intentions were when she left the ward or thereafter_ The medical cause of death was Hypothermia:
Circumstances of the Death
Pamela Margaret Bailey_had been an in-patient at Hawthorn Ward_Northern General Bailey and 23r being 29th 1a)
Hospital, Sheffield from the end of September 2012 She was initially detained under Section 2 and Section 3 of the Mental Health Act 1983 but then as an informal patient from December 2012_ The intention was for Mrs Bailey to eventually be discharged home and escorted leave was commenced, to be followed by unescorted leave. On the 23" March 2013, Mrs Bailey was on the ward at about 1830 hours. She exited the ward; obtaining egress through a locked door likely having observed the code required_ She was observed at 1831 hours on CCTV walking away from the Northern General Hospital, which was not only the last sig of her; but also the last evidence of her whereabouts. She was found deceased on the 29th March 2013 at an isolated, secluded location close to Ladybower reservoir , Derbyshire_ For the period 23r March to the 29th March it was both very cold and there was heavy snow lying on the ground,
Hospital, Sheffield from the end of September 2012 She was initially detained under Section 2 and Section 3 of the Mental Health Act 1983 but then as an informal patient from December 2012_ The intention was for Mrs Bailey to eventually be discharged home and escorted leave was commenced, to be followed by unescorted leave. On the 23" March 2013, Mrs Bailey was on the ward at about 1830 hours. She exited the ward; obtaining egress through a locked door likely having observed the code required_ She was observed at 1831 hours on CCTV walking away from the Northern General Hospital, which was not only the last sig of her; but also the last evidence of her whereabouts. She was found deceased on the 29th March 2013 at an isolated, secluded location close to Ladybower reservoir , Derbyshire_ For the period 23r March to the 29th March it was both very cold and there was heavy snow lying on the ground,
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.