The medical cause of death was:  
1 (a) Hypoxic Brain Injury Cardiac Arrest
Ligature Application and Plastic Bag Asphyxia  

The conclusion of the jury at inquest was a narrative conclusion, namely that:  
“Miriam carried out the deliberate act of ligating herself [REDACTED] on 18th February 2022, but in doing so, it is not possible to ascertain her intention.”  

The jury found that a lack of formal risk assessment, a safety assessment which did not include all relevant risks and an inadequate care plan were probable contributing factors in Miriam’s death. In addition, the jury found that the level of observations were likely assumed rather than individually assessed and that the level set, namely Level 3 every 15 minutes, was not appropriate.

Miriam has a history of various mental health disorders including Emotionally Unstable Personality Disorder, Schizoaffective Disorder, Schizophrenia and Bipolar.

Miriam was admitted on numerous occasions and had a long history of self-harm by various methods [REDACTED].  

Miriam was admitted to Hospital on the 15th February 2022 following an overdose. Whilst in hospital, Miriam undertook actions of self-harming and was distressed culminating in ligation whilst under 15 minute observations. This resulted in a decision to detain Miriam under Section 2 of the Mental Health Act. Miriam was admitted to the Mental Health Unit on the 17th February 2022 as considered to be a high risk of self-harm or completed suicide and hospital considered a place of safety and assessment.
 
Upon admission Miriam was presenting as calm and not in distress and was being monitored at 15 minute intervals. Miriam was interacting with staff but was not formally assessed  by  clinical  staff  and  a  safety  assessment  was  only  partially  completed.    No documented decision as to levels of observation or suicide risk exists to determine decisions made as to risk.
 
On the morning of the 18th February 2022, 13 minutes after being observed by staff, Miriam was not observable in her bed space and staff recognising the ward toilet door was locked, subsequently found Miriam in the toilet [REDACTED]. This was swiftly removed and revealed a ligature around Miriam’s neck [REDACTED].
 
Miriam was taken to hospital where she was intubated and ventilated. Despite treatment, her condition deteriorated and she died on 20th February 2022.