Health board failings contributed to death of Talygarn ward patient Deirdre Murakami, finds inquest

Deirdre Murakami died at the Talygarn mental health unit in Pontypool, where she was a patient, on May 11, 2016.

A jury in an inquest held last week returned a narrative conclusion, saying a number of factors had contributed to her death, including a failure on the part of the health board to ensure patients were checked on on a regular basis.

It was also found the health board had failed to reduce the number of areas on the ward where patients were able to self-harm, and not removed items patients could use to self-harm.

In its conclusion the jury said Ms Murakami “suffered from significant mental health problems, a combination of depression and emotional dysregulation personality disorder.

“These problems overwhelmed Deirdre, resulting in her death.”

“A lack of detailed documentation on triggers and risks specific to Deirdre’s time as an inpatient,” was also recorded as a contributory factor, after the jury heard that Ms Murakami’s care plan and assessments were not completed by ward staff.

The jury heard how Ms Murakami – who had a history of mental illness - had her level of observation downgraded to 'level one' two days before she died.

“This rapid change given Deirdre’s fear of abandonment issues and lack of evidence surrounding her ability to keep herself safe is a contributory factor,” they concluded.

The inquest, held before Senior Coroner for Gwent Caroline Saunders, also heard, although Ms Murakami should have been observed on an hourly basis, she was not checked on at 2am on May 11 after a nurse assumed the check had already been carried out. The same nurse found Ms Murakami dead in her room at 3am - by which point she had not been seen for at least an hour-and-a-half.

In their conclusion, the jury said: “Although we cannot agree whether failure to undertake hourly observations at 2am contributed, the process in place at the time was not in keeping with the observation policy which determines ‘at least hourly’.”

Following the conclusion of the inquest, Ms Murakami’s sister, Claire Murakami, said: “We’re happy that the failure of the NHS has been identified in contributing to Deirdre’s death because that is how we view it.

“We can’t bring her back - there are three children without their mother, and I have lost my sister.

“We are happy that it has been concluded after so long, and would like to thank the coroner and the jury.”

After the jury had been sent to deliberate, Sarah Cadman, head of quality and improvement in mental health and learning for Health Inspectorate Wales, gave evidence on the actions taken following Ms Murakami’s death, including a review of ward rounds a a requirement for new staff to shadow at least two observations before they are allowed to carry them out on their own.

In-patient units run by the health board have also been assessed for self-harm risk, and Ms Cadman said more than £2.5 million had been spent on these units to reduce the risk of self-harm since 2016.

Another recommendation was the 'level one' observation recording sheet was reviewed. This took place in December 2016, said Ms Cadman.

However Ms Cadman said the sheet used to record observations for 'level one' patients was “very similar” to the one used at the time of Ms Murakami’s death.

“When I asked how the sheet had changed, I was informed the recording was changed as opposed to the sheet,” said Ms Cadman.

A spokesman for Aneurin Bevan University Health Board said: “Our thoughts remain with the family of Ms Murakami. At the time of this tragic incident in 2016, the health board conducted a thorough Serious Incident investigation and we have since completed a substantial anti-ligature programme of works within patient areas. Further areas of work will be taken forward following the findings of the inquest.

“We have met with Ms Murakami’s family and shared the findings of our investigation, as well as a comprehensive action plan, fully and openly with them.”