Linda Hudson
PFD Report
Historic (No Identified Response)
Ref: 2013-0243
Coroner's Concerns (AI summary)
Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
View full coroner's concerns
(1) The deceased was discharged from hospital with 3 days prescription of her medication. In the community she had to collect her prescription on a daily basis to reduce the risk of self-harm or suicide. The Consultant Psychiatrist giving evidence at the inquest said that he was unaware of this.
(2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided.
(3) The deceased was discharged from hospital on the Thursday and no follow up visit from a nurse was scheduled until the following Monday. The Consultant Psychiatrist attending the inquest giving evidence confirmed that this was too long a time taking into account all of the circumstances of the case and a nurse should have made contact with the deceased probably the next day or the Friday though he was unable to say whether this might have made any difference in all the circumstnaces. 2
(2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided.
(3) The deceased was discharged from hospital on the Thursday and no follow up visit from a nurse was scheduled until the following Monday. The Consultant Psychiatrist attending the inquest giving evidence confirmed that this was too long a time taking into account all of the circumstances of the case and a nurse should have made contact with the deceased probably the next day or the Friday though he was unable to say whether this might have made any difference in all the circumstnaces. 2
Sent To
- Tees, Esk and Wear Valleys NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
22 Nov 2013
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 21st February 2013 I commenced an investigation into the death of Linda Hudson, Age 59 years. The investigation concluded at the end of the inquest on 24th September 2013.The conclusion of the inquest was that the deceased Took Her Own Life with a medical cause of death of 1a) Hanging.
Circumstances of the Death
The deceased had been admitted to Lanchester Road Hospital, a hospital run by Tees, Esk and Wear Valley NHS Foundation Trust following a previous suicide attempt and was discharged from the hospital on 14th February 2013. Upon discharge she was given a supply of medication which on balance was greater than that which she was able to have prescribed to her whilst in the community. In addition when she was discharged her family were not advised of this and there was thus no contact between them and the deceased. Following family concerns she was found dead in her house hanging on 16th February 2013 though it is unclear when she actually died.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.