Inquest told health board admits failing patient

Published date: 19 March 2014 |
Published by: Staff reporter
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A health body has admitted it failed a patient who died after she walked away from hospital.

The admission from Betsi Cadwaladr University Health Board (BCUHB) was made during an inquest for 44-year-old journalist Tracey Jane Murray.

As part of proceedings at the Guildhall in Wrexham yesterday, a statement about Miss Murray’s tragic life written by Top Gear presenter James May was read out.

The two corresponded with each other through social networking webiste Twitter.

Miss Murray was found dead in a stream at Bodelwyddan on April 1 last year after she had left Glan Clwyd Hospital without being discharged on March 30.

Miss Murray, of Radstock Close in Bolton, had been admitted to the hospital after taking an overdose in Llandudno and was being cared for on a surgical ward when she decided to leave.

Matthew Makin, executive medical director of BCUHB, said there was an intention to refer her to the psychiatric team, but that was never actually made.

“We fell short in meeting her psychological needs,” Mr Makin said.

At one point Miss Murray’s sister, Shirley Reynolds, of East Renfrewshire, accused the health board of negligence, but North East Wales and Central Coroner John Gittins stressed that was not a matter for the inquest to decide upon.

Mr Gittins also emphasised there was no way of knowing what the outcome of a psychological assessment on Miss Murray would have been.

Mr Gittins expressed concern that nearly 12 months after the tragedy the health board still hadn’t fully implemented operating policy revisions.

Mr Makin said it was an ongoing process, although protocols were in place they were currently in draft form. He expected everything to be ready within about six weeks and agreed to keep Mr Gittins informed.

Following Miss Murray’s death a serious incident review had taken place. On the issue of referrals to the psychiatric team, steps which had been taken included a series of mandatory staff training events.

At the time Miss Murray left the hospital, nurse Melanie Fowler made an unsuccessful attempt to try to encourage her back to Glan Clwyd.

Miss Fowler was praised by Mr Gittins for her efforts. He said she was a credit to the nursing profession.

Miss Murray’s absence was reported to hospital authorities and a decision then made not to go after her, she had shown a capacity to understand the situation she was in.

The reason Miss Murray was in a surgical ward before she left was to help accommodate a large flow of patients at Glan Clwyd.

Mrs Reynolds said her sister had developed agoraphobia earlier in life and in about 2009 she underwent a hysterectomy that was later found to be the result of a misdiagnosis of ovarian cancer.

In his statement Mr May, who co-presents Top Gear with Richard Hammond and Jeremy Clarkson, said Miss Murray blamed the medical profession and referred to doctors as “Rippers”.

Mr May said he started to correspond with Miss Murray on Twitter after she joined a discussion about poetry. The two never met in person.

Mr May described Miss Murray as being well read and could be fun.

“She had more than 500 followers on Twitter, which is a lot for a private individual. After a while I got private messages from her.”

Mr May said sometimes Miss Murray would write in a rambling fashion and she said her life was falling apart.

“The normal response is to unfollow. But there was something about her, a soul in some torment,” Mr May wrote in his statement.

Just a few days before her death Miss Murray wrote: “I am so utterly alone, apart from a couple of people who have tried to help me. I hate the world, it bleeds you dry.”

A post-mortem examination was carried out by Dr Andrew Dalton which found Miss Murray had died as a result of drowning.

Recording an open conclusion Mr Gittins said: “She was a young woman who came to a tragic end in circumstances where she felt partially abandoned.”

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