A hospital trust missed 14 chances to help a highly respected but troubled police officer who hanged herself on an understaffed Pinderfields hospital ward, an inquest was told.
Coroner David Hinchliff ruled that Mid Yorkshire Hospital Trust was responsible for “gross failures” in the care of Andrea Jayne Shelton.
And that her death could have been avoided if the trust had not missed 14 opportunities to provide appropriate care and assess her mental health.
Mrs Shelton, 45, of Low Ackworth near Pontefract, worked in the operations department of South Yorkshire Police and had been planning and co-ordinating the March 2011 Liberal Democrat party conference in Sheffield.
Mr Hinchliff said she had to use a ‘Clio’ computer software package which “troubled her and preyed on her mind causing her anxiety and distress.”
On the weekend of January 15 and 16 2011, Mrs Shelton brought work home with her and had problems sleeping.
She used a kitchen knife to cut her wrists and groin in the early hours of January 17 201 and was taken to Pontefract Hospital.
A nurse at Pontefract was so worried about Mrs Shelton’s mental health that she had oxygen tubing removed from the cubicle.
Mrs Shelton was transferred to Pinderfields Hospital, in Wakefield, later on January 17 where she underwent surgery on her groin wounds and was later admitted to a busy ward staffed by two relatively inexperienced nurses.
Her husband Paul, also a police officer, asked to stay with her that night but was told he couldn’t.
At 9.30am on January 18, a doctor had faxed a mental health referral request to the trust’s Mental Health Liaison Team.
But no action was taken until 2.30pm that day and a review was not planned until 9am on January 19.
At 4am on January 19, a night nurse found Mrs Shelton hanging by a dressing gown cord tied to a shower pipe.
Recording a narrative verdict, Mr Hinchliff said the 14 failures and missed opportunities “constitutes gross failures to provide Jayne with appropriate care and attention regarding her mental health and I consider that her death could have been avoided.”