Inquest investigates death of woman who died days after being discharged from Solent NHS Trust hospital

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An inquest has resumed to investigate the death of a ‘well educated’ and ‘capable’ woman who died days after being discharged from hospital.

Victoria Wemyss, Portsmouth, was admitted to Hawthorn Ward at The Orchards and Limes AMH Inpatient Unit on Locksway Road, Southsea on August 13, 2021 after being sectioned under Section 2 of the Mental Health Act. The 30-year-old was in hospital until August 18 when she was discharged but three days later on August 21, her body was found at Candy’s Pit, London Road.

An inquest has today (April 18) resumed at Portsmouth Coroner’s Court after a two-day hearing in October of last year at Winchester Coroner’s Court. Today, senior coroner Christopher Wilkinson, heard how Victoria was diagnosed with manic depression back in 2013, a psychotic disorder in 2016 and she was also possibly experiencing schizophrenia. The coroner described Victoria as a ‘well-educated’ and ‘capable woman’.

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She was taken into the care of the Solent NHS Trust following sectioning in order to provide her with necessary medication and because she was believed to be of ‘high risk’ to herself.

During her time in the hospital, she was put into an isolation corridor to follow Covid guidelines in place at the time but this level of isolation caused Miss Wemyss to become upset. The inquest heard how she was taken into hospital to receive medication in the form of an aripiprazole injection as she had refused her medication for numerous months.

It was heard how she received the 300ml injection on August 16 and needed to continue taking the medication orally after being discharged for two weeks despite a history of being non-compliant with taking medication.

During an ‘interview’ with Dr Ajmal Kudlebbai, working as a locum psychiatrist for Solent NHS Trust between March 2021 and September 2021, she said that she wanted to be discharged and return to work.

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Dr Kudlebbai said: “There was one episode that I heard about from staff where she was upset and distressed but she calmed down with anti-agitation medication. The risk may have been chronic but there was no risk of her wanting to end her life. 

“Miss Wemyss did agree and did talk about her mental health and she was upset because she didn’t like how she was sectioned but she was willing to tackle the problems. 

“I was aware of this that five years ago she had jumped from a window and broken her spine, but the fact that she had been stable for many years meant that I didn’t have any concerns.”

Portsmouth Coroner's Court in Guildhall Square. Picture: Malcolm Wells (180405-3355)Portsmouth Coroner's Court in Guildhall Square. Picture: Malcolm Wells (180405-3355)
Portsmouth Coroner's Court in Guildhall Square. Picture: Malcolm Wells (180405-3355)

When being questioned by Maryam Ahmad, the legal representation for the Wemyss family, Dr Kudlebbai said that "things could have been done better, a lot better” in relation to the procedures taken when discharging Victoria as it was unknown at that time that she did not have a GP. It was also acknowledged that she did not have a ‘suitable’ care programme approach meeting ahead of leaving hospital.

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During an episode on August 16, a witness statement told how Victoria was "shouting, screaming, hearing voices and being agitated” and had to be medicated to calm down. A nurse spent one-on-one time with Victoria where she was told that she “has been given commands to hurt herself” and she “does not think anything helped to quieten down the voices.”

Ms Ahmad read notes from the mental health assessment of Victoria which led to her admission, which said: “She is a high risk to health and self –  if not treated, risk to her health and self will increase.” 

The inquest also heard a statement from Dr Elfar, Victoria’s treating doctor, who wrote on August 11: “She said she had suicidal thoughts recently but not at the time of the interview - she is hesitant about medication, she said it is an admission of her as a psychotic.” 

The note also depicted how Victoria would commonly mask her symptoms in order to conceal what she was experiencing.

The inquest has been adjourned and is due to conclude tomorrow (April 19).

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