Newbury woman takes own life after going missing from hospital ward

Staff waited six hours before reporting 50-year-old as missing, inquest hears

A MENTAL health patient who had returned to her Newbury home to take her own life was not reported as missing by hospital staff until hours later, an inquest heard.

Staff at Prospect Park Hospital, Reading, waited six hours before reporting Tracy Caldwell missing after she failed to return from a day out on Friday, November 20, last year.

Police found the 50-year-old’s body at her home address in Andover Road two days later.

Family members at the inquest, held in Reading Town Hall on Tuesday, told the coroner that staff at the hospital should accept responsibility for her death.

Doctors had considered Ms Caldwell, who had been suffering from psychosis and emotionally unstable personality disorder, at ‘low risk’ of self-harm while she was on the ward.

She had regularly told staff members that Satan was going to kill her at her home, and made attempts to take overdoses in the past.

She had also expressed concern that doctors would discharge her from the ward where she was staying as an ‘informal patient’ – meaning she could leave the grounds with the permission of staff.

According to the coroner, staff had become familiar with Ms Caldwell and, as a result, possibly complacent over the risk she posed to herself.

Once missing, she was still considered a ‘low risk’, while it was deemed unlikely that Ms Caldwell would return to her house, owing to her fear of Satan.

As a result, her Andover Road address was not checked until the following day.

Police visited her home on the morning of Saturday, November 21, and were told by neighbours that noises had been heard inside the house at around 4.30pm on the Friday.

However, officers did not attempt to gain entry to the property because of her low-risk categorisation.

It was only after Ms Caldwell had been missing for more than 24 hours and her risk level had increased to ‘high’ that police were able to force entry into her property on the morning of Sunday, November 22.

Her body was found lying on the floor in the living room.

A toxicology report found an “incredible” amount of alcohol in her blood, which would have put her almost 10 times over the drink drive limit.

There were also various anti-psychotic medications present in her system.

The inquest heard how, since the incident, a number of changes had been made at the hospital to ensure swifter action is taken and that risk levels are upgraded as soon as a patient is unaccounted for.

However, addressing the coroner, Ms Caldwell’s aunt Delia Nelwyn said: “I feel the hospital must take some of the responsibility for this.

“Why weren’t these recommendations in place before and if they had been it could have saved her life.

“To me, there are so many factors – irresponsible people in jobs, taking care of mental health patients, who didn’t follow a normal procedure, I feel they should be held responsible.”

When asked if there was any reason why Ms Caldwell would have returned to the house, Ms Nelwyn said: “She had shared the house with her mother, who had died of cancer.

“Tracy had it in her mind to do what happened – and she would have wanted to be at home, where her mum died.”

Recording a verdict of suicide, senior coroner for Berkshire Peter Bedford said it was “surprising” that staff waited six hours to report a patient missing.

And while he admitted that had the recommendations been in place at the time of Ms Caldwell’s death, he could not be certain that her life would have been saved.

However, he added he was confident lessons had been learned and the recommendations by the trust had been implemented.