A communication error resulted in the transfer of a mental health patient to a hospital – a move that went against explicit requests in her medical records.
Louise Furlong then died just five days after her arrival at Highbury Hospital in Nottingham, which is run by Nottinghamshire Healthcare NHS Foundation Trust, after a healthcare worker who was tasked with checking on the 19-year-old every 10 minutes sat on a sofa instead.
However, Louise should not have been at Highbury in the first place because of a “suicide pact” she had with another patient there – Sophie Towle, who also died as a result of the same hospital trust’s neglect 18 months later.
Notes warned that Miss Furlong should not be moved to Highbury from Bassetlaw Hospital, near Worksop, while Miss Towle was still there.
But an error led to the transfer taking place overnight without staff at Bassetlaw knowing – leaving those caring for her “gobsmacked” to find she had vanished the next morning.
Miss Furlong’s inquest, taking place in front of a jury at Nottingham Coroner’s Court nearly three and a half years after she died, heard evidence about her transfer from Bassetlaw on Tuesday, 17 February.
The hospital’s operations manager at the time Louise was there, Joanna Hill, was called to give evidence.
Coroner Alexandra Pountney heard how Ms Hill was in charge of bed management for hospitals in the north of Nottinghamshire after Louise’s admission in June 2022.
The inquest previously heard how Miss Furlong wanted to move to Highbury to be closer to her family and friends.
Although there were no bed spaces available at Highbury, it was noted that she should not go until Sophie was discharged or moved elsewhere.
As time went on, however, Louise’s behaviour became increasingly difficult to manage for those at Bassetlaw.
She was regularly self-harming when granted leave, which led to both the police and ambulance service contacting the hospital, and the senior management team had concerns.
Staff were hesitant to restrict her leave, though, because the B2 ward at Bassetlaw Hospital had no outdoor space Louise could access without actually having to leave the hospital, and the teenager “felt cooped up” when indoors and appreciated fresh air, the court heard.
By contrast, Nottinghamshire Healthcare’s other two acute psychiatric wards suitable for Louise – Highbury and Millbrook at King’s Mill Hospital (now Blossomwood) – had gardens right outside the bedrooms.
The situation came to a head on 7 September 2022 when, fearing that they could not keep Louise safe at Bassetlaw, Ms Hill put Louise on the “transfer list” for a potential move.
The plan was to discuss the move with Louise’s multidisciplinary team – including Louise herself, the clinical psychologist on the ward and other managers – the next morning.
The meeting would discuss whether other options could be considered to avoid the destabilising nature of a transfer or, if it was unavoidable, where she should go.
However, on the night of 7 September, when all the regular staff had gone home, a bed space became available at Highbury and the transfer team arrived, took Louise and moved her.
Ms Hill arrived the next morning to find her gone, as did the clinical team with the medical training to support Louise – who had not even been told she was being put on the transfer list.
Ms Hill told the inquest she was “gobsmacked” to find Louise gone and admitted that she, as part of the senior management team, and the clinical team had no control over the move.
Five days later, Louise was found with a ligature around her neck in her bathroom at Highbury.
She died the next day.
The inquest into her death was delayed due to the protracted legal proceedings against Sylwia Quaye-Mensah, the staff member who was meant to be checking on her in the hour before she was found unconscious on 11 September 2022.
After Ms Hill had given evidence, the court heard from Rebecca Keating, Nottinghamshire Healthcare’s clinical director for acute care in adult mental health.
She explained what had been done at the trust to improve since Louise’s death.
Immediately afterwards, several investigations took place – one by an external company and one internally, with an additional report produced by the trust after the external investigation.
There is now an internal “transfer checklist” at the trust, which includes a requirement for a discussion with the patient and the MDT before any transfer.
Transfers are audited monthly using a sample of 10 cases to confirm all aspects of the checklist have been covered, and internal meetings take place every day regarding safe care and bed prioritisation.
The inquest is expected to conclude this week.
• 19-year-old died 5 days after unannounced transfer between Nottinghamshire hospitals