Guidance warning after hospital patient's death

A woman with paranoid schizophrenia who ran away from a mental health worker on a trip out from a psychiatric hospital was later found dead in a flat, an inquest has heard.

Hayley Cowan was being detained at the Edenfield Centre within Prestwich Hospital near Manchester, when she was taken out in June 2022 and ran away when she and her support worker both went to the toilet.

In a prevention of future deaths report (PFD), sent to the Department of Health and Social Care, the coroner said guidance on taking patients on escorted leave was "inconsistent".

The department said it would "respond to and learn from" the report.

Greater Manchester Mental Health NHS Foundation Trust, which runs the Edenfield Unit, has been contacted for comment.

The inquest into Ms Cowan's death heard she and her support worker had both gone to use the toilet in a Tesco supermarket on 4 June when she ran away.

She was later found dead at a friend's flat after taking drugs.

Joanne Kearsley, senior coroner for Manchester North, said Ms Cowan, who had a long history of drug use, had been described as a "risk to herself and others".

Ms Cowan had been detained at the unit since 2021 after setting fire to her flat.

The PFD said Ms Cowan had "responded well" to anti-psychotic medication.

However, Ms Kearsley wrote: "At all times she was considered to be at risk of absconding which was driven by her urge to use drugs."

Ms Cowan was granted what is known as Section 17 leave under the Mental Health Act, which allowed her trips out of the hospital grounds into the local village.

However, she had run away on two previous occasions and took drugs before returning to the hospital.

Ms Kearsley said while there was national guidance to mental health staff on what to do if a patient on escorted leave needed to use the toilet, there was none on what to do if a staff member also needed to.

She described the Mental Health Act Codes of Practice, Guidance from the Ministry of Justice to forensic providers and local trust policy as inconsistent.

She added: "This is particularly the case in considering whether a patient needs to be 'within eyeline' or a 'reasonable distance' when on leave."

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