A vulnerable woman from the Midlands died after being left alone in a bathroom at a specialist mental health facility, despite being under strict 24-hour supervision, a coroner's court has heard.
A Tragic Failure of Supervision
Georgina Hallam, a 47-year-old from Nottingham, died on 8 August 2022 at the Bradley Complex Care Apartments in Grimsby, Lincolnshire. The facility is managed by Elysium Healthcare Ltd. Ms Hallam, who had cerebral palsy, learning disabilities, a speech impediment and partial deafness, was supposed to be under constant one-to-one observation due to her history of severe self-harm.
However, on the evening of 4 August 2022, a temporary male healthcare assistant, who was not a regular member of staff and was unfamiliar with Ms Hallam, allowed her to enter a toilet unaccompanied. While alone, she ingested a foreign object in an act of self-harm.
Systemic Failings in Care
The inquest at Greater Lincolnshire Coroners Court, led by Coroner Jayne Wilkes, heard a catalogue of errors. The temporary worker was on shift because measures to "manage shift cover adequately" were not in place. Furthermore, staff had not received proper reminders about the critical need for vigilance regarding Ms Hallam's specific care plan.
Barristers for Ms Hallam's family stated her care programme was "very clear" and the need for one-to-one supervision, even during bathroom visits, was explicit. The coroner found there were "inadequate safeguards in place" to manage the known risks of her harming herself.
Approximately five minutes after she entered the toilet, a female colleague found Ms Hallam collapsed on the floor in "significant distress". Although paramedics restored her pulse, she suffered catastrophic brain damage due to lack of oxygen and died three days later.
Broader Responsibility and a Family's Anguish
The hearing was told that Nottinghamshire County Council, responsible for her social care before she moved to the facility, had failed to properly assess her mental capacity. This led to those involved in her later care misunderstanding her complex needs.
Her brother, Anthony, said: "I find it hard to comprehend how a facility which is supposed to specialise in looking after vulnerable people like Georgina can fail to follow care plans which have been specifically put in place to protect them. This was clearly a failure to follow procedures."
He added that had the plan been followed, "Georgina would never have had the opportunity to do what she did".
Iftikhar Manzoor of Hudgell Solicitors, representing the family, said: "Georgina was completely let down... A life was lost here because the most basic of instructions were not followed. These were inexcusable failings." He highlighted a lack of effective systems to ensure enough female staff were on shift and that agency workers were properly briefed.
Conclusion and Response
The coroner recorded a conclusion of "misadventure". The inquest heard Ms Hallam, described as emotionally unstable, likely had no intention of ending her life but was "seeking attention" and would not have understood the potentially fatal consequences of her actions.
A spokesperson for Elysium Healthcare said: "We continue to send our deepest condolences to Georgina's family and friends... A comprehensive and detailed investigation was carried out... and as a result enhancements were implemented concerning observation policies and staff training." They noted the coroner was satisfied the facility is a safe place and that it holds a 'Good' rating from the Care Quality Commission.
Nottinghamshire County Council was approached for comment at the time of the inquest.
