Errors led to patient death
A fatal catalogue of three dozen errors amounting to neglect allowed a Mid Wales artist on suicide watch at a psychiatric unit to hang herself, a coroner has concluded. Chronically depressed Sylvan Money, 26, of Presteigne, used her nightgown cord to hang herself from her bedroom curtain rail at the unit.
Her death came within a week of a failed attempt to take an overdose and days after she was admitted to the psychiatric unit at Bronllys Hospital, Brecon, in January 2004.
Powys coroner Geraint Williams listed 36 separate errors which led to her death as he yesterday recorded a narrative verdict contributed to by neglect.
In a three-hour summary of three weeks of evidence at the inquest at Ystradgynlais he also expressed disbelief, anger and deep irritation at many of the staff responsible for Sylvan's care.
Her parents spoke afterwards of their grief of allowing their daughter to enter the unit. After hearing more than 30 witnesses detail Sylvan's final days, parents Christopher Money and Carol Horne, said: "We are still filled with overwhelming grief and desperation for ever admitting Sylvan into such an environment.
"We thought she was safe and would be looked after. But if we had not done that, she would still be here today."
Ms Horne said she had no faith that the health board was capable of making the changes needed to the way the unit operated. "For me they are obviously not capable of doing that themselves. Some outside body, such as the Health and Safety Executive, should come in and oversee what they do."
With regard to the verdict, she added: "We could have written that ourselves two-and-a-half years ago. It has taken until now for it to come out."
Marjorie Wallace, chief executive of mental health charity Sane, said: "Sylvan Money is one of the 167 patients who take their own lives each year while supposedly being cared for in the safety of a hospital unit.
"Although it was known that she was at high risk of suicide, and it is also known about the dangers of ligatures in in-patient suicides, Sylvan was failed by the very people and systems who should have protected her."
By Liza Radley
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