An inquest has found flaws in the care of a much-loved mum by a troubled mental health trust, after she took her own life.
Donna Jane Levin had been a patient at Roseberry Park in Middlesbrough, run by the Tees, Esk and Wear Valleys NHS trust, for just a week when an incident in her room left her in intensive care.
The 54-year-old teacher from Stockton suffered an “irreversible” brain injury and died at James Cook University Hospital four days later on January, 8, 2020.
On Tuesday (July 29), after listening to five days of evidence and spending seven hours deliberating, a jury at Teesside Coroners’ Court concluded Mrs Levin’s death was “suicide due to suffering from a mental illness”.
They found a series of flaws in her care, but did not say any contributed directly to her death.
The jury noted "short comings" in a handover by hospital staff which “didn’t include all the information” the next shift needed. This included information about Donna’s suicidal thoughts on the day before she was found in her room, including discovery of a note by her family, phone call to her son “to say goodbye”, and her expressing that she wanted to kill herself.
Donna was sectioned in the early hours of the morning of the incident but she was not re-assessed and risk plans weren’t updated.
The jury said there were “incomplete” electronic documents and a record of hourly observations was “falsely completed” when one check was missed in the hours before she was found.
When a staff member discovered her, they did not have their alarm with them as it was on charge, causing a delay getting her CPR.
Paramedics were also slowed getting to her room as access gates at the hospital were locked.
The foreman of the jury said: “We conclude Donna’s death as suicide due to suffering a mental illness.”
The inquest heard Donna struggled with her mental health from around the start of the new school year in 2019 and was treated at home but her condition worsened and she was admitted to the hospital in December.
Senior Coroner for Teesside Clare Bailey added: “I wish to extend my condolences to those that have been affected by Donna’s death, particularly Donna’s family, and I want to acknowledge their strength during this investigation and inquest.
“It’s clear to me that Donna was part of a close and loving family and had very dear friends also.
In a statement read to the inquest last week her Stuart husband said: “Donna was a very friendly, outgoing person with a beautiful, gregarious personality. She was always full of joy and went through life with a permanent smile. She was full of fun and happy to have a go at anything.
“She loved her job and put her heart and soul into it and wanted her students to reach their full potential.
“Donna had a massive heart, filled with love and compassion for others. She went out of her way to to support her friends and colleagues.
“She was a devoted mum who adored our three children, and a wonderful wife. Today our family is missing a wonderful personality and one of the nicest people you could ever meet.
“We are devastated at what has brought us here today and are left with a hole in our lives with pain that sometimes seems unbearable.
“Every day without Donna is a day closer to us being reunited.”
Beverley Murphy, chief nurse at the trust, said: “We don't underestimate how difficult and painful this has been for Donna’s family. Our thoughts go out to all those who loved and cared for Donna. We are deeply sorry for their loss.“An independent review into Donna’s care took place after her death in 2020, and we listened carefully to the concerns raised by her family. We made changes as a result and those changes have been sustained.
“We understand how important it is to involve families and carers, to make sure their voices are heard and included in the care of their loved ones. We are committed to doing this for everyone we care for.”
Read more:
- Mum told hospital staff she 'wanted to end it' days before being found unresponsive
- Mum found unresponsive on TEWV ward 'day after staff said they'd keep her safe'
- Hospital staff missed check on much-loved mum hours before she was found unresponsive
- County Durham man was not seen by psych team after suicide attempt, inquest hears
- Coroner put in charge of cases of three girls who died in care of troubled NHS trust
If you are in need of support you can contact the following:
- Samaritans is available, day or night, 365 days of the year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
- If U Care Share on 0191 387 5661 or text IUCS to 85258
- SANE on 07984 967 708, Calm on 0800 58 58 58
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