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Novum Law is representing the family of Azra Parveen Hussain (nee Sultan), a 40-year-old mother of four, who tragically died on 6 May 2020 at Mary Seacole House, a mental health hospital run by Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHT) after several missed opportunities to keep her safe.

Azra had a history of bipolar affective disorder (BAD).  On 26 December 2019, she was sectioned under the Mental Health Act 1983 and admitted to Mary Seacole House suffering from mania caused by her illness.  Following admission, Azra’s manic episode gave way to severe depression.

On 24 March 2020, she was taken for electroconvulsive therapy (ECT) to treat her ongoing depression and suicidal thoughts.  An administrative error meant that the treatment was not able to commence.

Azra’s mental health deteriorated further. Her risk materially increased on 4 May 2020 when she changed from talking about committing suicide to actually attempting to take her own life by trying to tie a ligature with shoelaces.

The staff on duty failed to respond adequately or properly document the incident or raise an incident report. Crucially, Azra’s risk assessment was not updated, and other hospital staff, including her treating doctors, were not informed of her suicide attempt.  In total, there were four missed opportunities to act on or pass the information on.  There was no increase in the level of observations for Azra and other objects that she could potentially use as ligatures were not removed from her room.

On 6 May 2020, Azra used a bedsheet to hang herself from the en-suite bathroom door in her room and was later found by staff on a routine check.

Azra’s family was excluded from remotely participating in a multidisciplinary team meeting (MDT) which took place just hours before her death.  This presented a further missed opportunity for concerns to be voiced about  Azra’s safety.

At an inquest at Birmingham and Solihull Coroner’s Court, which concluded this week, evidence was heard that Azra was the seventh in-patient of the Trust to use an en-suite bathroom door to hang themselves since 2013. Despite this, door pressure sensor alarms (available from multiple manufacturers for over 10 years) had not been installed by the Trust.

The jury concluded that there were three failings that led to Azra’s death:

1. On the 24th March 2020 there was a missed opportunity to commence ECT treatment and it is likely that Azra’s death would have been prevented if she had undergone ECT.

2. On the 6th May 2020 there was a foreseeable risk that Azra would attempt suicide, that risk had not been adequately identified by those caring for her, adequate measures had not been taken to mitigate her risk and with adequate measures, it is likely that Azra’s death would have been prevented.

3. On the 6th May 2020 there was a foreseeable risk that the en-suite bathroom door would be used as a ligature point, adequate measures had not been taken to mitigate the risk and with adequate measures, it is likely that Azra’s death would have been prevented.

HM Area Coroner, Emma Brown, noted that while BSMHT is now taking action to install pressure sensors on en-suite bathroom doors at Mary Seacole House, there is a lack of national regulation or guidance on the risk presented by internal doors in patients’ bedrooms.

She has issued a Regulation 28, ‘Prevention of Future Deaths’ Report on two fronts:

1. That BSMHT, the Clinical Commissioning Group (CCG) for Birmingham and Solihull, Care Quality Commission (CQC) and the Health & Safety Executive (HSE) take action to remedy the persisting risk posed by the lack of sensor alarms in areas where patients spend time, unobserved, in mental health units operated by Trusts and private providers around the country.

2. That BSMHT ensures that families can attend MDT meetings, using a remote platform or by telephone.

On 23 November 2020, following Azra’s death, the Care Quality Commission (CQC) conducted an unannounced inspection of BSMHT, including Ward 2 of Mary Seacole House, where Azra had been a patient.  Following their inspection, the CQC put conditions on BSMHT’s registration, requiring them to implement an effective system to improve risk assessments and care planning by 5 February 2021 and to address all ligature risks by 18 June 2021.

The CQC’s Head of Hospital Inspection (mental health and community health services), Jenny Wilkes, said:

“We (have) imposed urgent conditions on the trust’s registration as a result of our concerns about ligature risks, care planning and risk assessments. We took this urgent action to ensure that people using the services are not exposed to any risk of harm.”

Mary Smith, Associate Legal Director of Novum Law and mental health inquest lawyer, who is acting for the family, said:

“Azra’s inquest and the recent CQC Report expose several deeply troubling failings that led to her tragic, avoidable death.  Most shockingly of all, the Trust appears to have wholly failed to learn from six earlier deaths in similar circumstances, by ensuring installing a simple pressure alarm system.

“Death by hanging is one of the most common methods of suicide in mental health patients.  Patients detained under the Mental Health Act have a right to expect to be kept safe by those responsible for their care, both through adequate risk assessment and observation and in ensuring that the enviorment they are cared for in is a safe one.

“The jury’s verdict and Prevention of Future Death Report issued by the coroner is welcome.  It is vital that when things go wrong, lessons are learnt, and the risk of any future harm is prevented.  The hope now is that those with the power to make the necessary changes do so.”

Azra’s children, who sadly are now orphans, said:

“Mum was the foundation of our family and the reason why our house felt like home. Without her, it feels like the beams that held the family up are now gone.  She was truly cherished. It is difficult to articulate what a beautiful and pure-hearted person she was.

“With the assistance of our legal team, the coroner and the jury, we have now taken the first step towards justice for mum and to make things safer for others.  This means everything to us.  Although there will always be a void in our hearts, we now feel a little less empty.”

Watch BBC Midlands Today’s news report into the circumstances that led to Azra’s tragic death.