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Coroners report highlights failure to apply the Mental Capacity Act on a mental health ward



Emily Caldicott: Report to prevent future deaths

Emily had emotionally unstable personality disorder and was a voluntary patient in a mental health hospital. The Coroner’s jury found her death was contributed to by neglect.


The coroners report (23 March 2022) states: ...the jury found that if an adequate assessment of Emily's capacity had taken place, she would have been given IM Lorazepam "in best interests", that this would have quickly relieved her anxiety and distress, and that her death would probably have been prevented.’


‘I am concerned that if a such a decision has to be made in similar circumstances in the future, staff may not apply the correct test under the Mental Capacity Act 2005, and there is therefore a risk of future deaths occurring.’


Emily died after tying a ligature around her neck whilst on the ward.


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