NHS staff watched Shannara Donnelly, 22, die on CCTV because they presumed she was sleeping

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Donnelly, known as Jade by her family, had previously reported sexual abuse, had struggled with alcohol abuse and sometimes heard “voices” in her head, the inquest heard.

Her mother, Kerry, said her daughter had struggled during the Covid lockdown and had recently lost three close members of her family before she died.

She was an active member of both the Army and Police cadets, as well as being a member of the Royal British Legion.

‘Deep-rooted in our hearts’

Paying tribute, her mother said: “Jade always liked doing different things and whatever she did she generally put her heart and soul into it. A very beautiful leaf fell from our family tree, but the memories of Jade will remain deep-rooted in our hearts forever”.

A note on her health documents stated that Donnelly should not be sent to Chase Farm Hospital because of a previous incident but she was re-admitted anyway.

A few days before being re-admitted, she was arrested after she told police officers she “wanted to die” and threatened to harm herself.

Her condition meant she required “one-to-one” care and continuous observation “24/7, seven days a week”, jurors heard.

Risk assessment was inadequate

Barnet, Enfield and Haringey Mental Health NHS Trust admitted “shortcomings” in Donnelly’s care and acknowledged that her risk assessment was inadequate and that the young woman “shouldn’t have been sent” to the hospital.

The Trust also admitted that she “should have been within eyesight observations”.

CCTV footage played in court showed members of staff observing Donnelly on cameras and through peephole windows, but the trust said that using CCTV was an inadequate form of observation and that staff failed to carry out safety checks.

Trust guidelines state that staff can use CCTV to observe patients but that it should not be used to replace other forms of observation and engagement.

Mark Pritchard, the trust’s director, apologised to Donnelly’s family as he admitted “shortcomings” in her care.

‘Verbal contact’

Donnelly’s family’s lawyer, Ross Beaton, later questioned Mr Pritchard on whether Donnelly’s level of care was provided effectively.

Mr Beaton said: “Level Three means being within eyesight unless [the patient] is in the bathroom, in which case you will be in verbal contact [with them]. Did you see any Level Three observations [in the CCTV footage]?”

Mr Pritchard replied: “The bulk of it, I would say no… The overarching answer is no.”

The inquest continues.



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