A mental health hospital was “severely short-staffed” and missing “at least half” their workers on the day a vulnerable teenager fatally self-harmed, an inquest has heard.
Ruth Szymankiewicz, 14, died on 14 February 2022 after she was left alone at Huntercombe Hospital, near Maidenhead in Berkshire, despite requiring constant one-to-one observation, Buckinghamshire Coroner’s Court was told.
Ruth, who had an eating disorder, Tourette syndrome and a tic condition, which had affected her mental health, was left alone for 15 minutes on 12 February, allowing her to make her way to her room, where she self-harmed. She was found and resuscitated before being transferred to John Radcliffe Hospital, but died two days later.
It later emerged that the care worker responsible for watching Ruth at the hospital’s psychiatric intensive care unit – a man then known as Ebo Acheampong – had been using false identity documents and was hired under a false name.
Ellesha Brannigan, who worked as a clinical team leader on the ward where Ruth was staying, said they were understaffed on the day the teenager was left alone.
She told the inquest: “On this day, we were severely short-staffed when we had come in for a shift. We were missing at least half of our staff this day, and we really struggled to get staff to cover the observation levels. We needed the ward below us to send us staff during break times to enable staff to take breaks. Otherwise, breaks wouldn’t have been possible.”
She added: “Staffing was an issue for a long time, for a very long time there. It always was an issue, and me and other staff advocated for our ward and had several meetings with higher management about these staffing levels, but no changes were made.”
On the day Ruth self-harmed, a worker raised the alarm on the low staffing levels by recording it as a safety incident, known as a datix.
They wrote: “We’ve got inadequate staffing levels here” and warned that patient “observations might not be able to be kept” and cited “patient harm”, the court heard.
Ms Brannigan said that Mr Acheampong was called to work on the ward that day due to short staffing. The senior nurse also said that due to staffing issues, there was only one staff member available per two patients who both needed regular in-person checks.
She said that shouldn’t happen, but “often” did due to a lack of available staff.
CCTV footage from the ward on the day Ruth was found unresponsive, shown to the court, revealed Mr Acheampong left Ruth alone in a lounge just after 8pm.
His shift was due to end at 8.15pm, however, hospital protocol is for a staff member not to leave a patient needing one-to-one observation until they have handed over to another member of staff, Ms Brannigan told the court.
In the footage, Mr Acheampong can be seen leaving the room repeatedly – at first only for seconds at a time, then for two minutes – prompting the teenager to walk up to the door and look into the lobby, seemingly waiting for the opportunity to leave the room.
“Ruth is very aware that she is being left on her own,” coroner Ian Wade KC told the inquest. “Whichever way one looks at it, there has been an egregious breach of level three observation.”
The court also heard how new support care workers joining Huntercombe were required to complete an induction process with a chief nurse, who would then need to sign a checklist or the shift would have to be cancelled, Tim Moloney KC, representing the family, told the hearing.
This was not done for Mr Acheampong, with Ms Brannigan explaining: “We didn’t have the staff to do the induction for him.”
If you are experiencing feelings of distress or are struggling to cope, you can speak to the Samaritans in confidence on 116 123 (UK and ROI), email [email protected], or visit the Samaritans website to find details of your nearest branch. If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week. If you are in another country, you can go to befrienders.org to find a helpline near you.
For anyone struggling with the issues raised in this article, eating disorder charity Beat’s helpline is available 365 days a year on 0808 801 0677. NCFED offers information, resources and counselling for those suffering from eating disorders, as well as their support networks. Visit eating-disorders.org.uk or call 0845 838 2040
