Helen Tarry, a mental health patient, was found dead on farmland, having walked out of a supposedly secure Priory hospital ward on Christmas Day.
The 52-year-old managed to tailgate a staff member through locked doors before triggering a fire alarm and fleeing the Arnold, Nottingham hospital.
Her body was discovered by a dog walker the following morning.
Inquest Findings:
The inquest into Helen Tarry’s death revealed serious failings by both the hospital and the police, contributing to the tragic outcome.
Jurors at Nottingham Coroner’s Court returned a conclusion of misadventure with a narrative verdict, citing communication failures, inadequate risk management, missed opportunities to mitigate risks, insufficient senior oversight, and confusing record-keeping.
Police Admissions and Missed Opportunities:
Nottinghamshire Police, criticized for recent misconduct over a WhatsApp group incident, admitted “missed opportunities” during the inquest.
The force failed to dispatch officers to the scene after being notified of Tarry’s absconding.
The inquest highlighted the inadequacy of police staffing on the night of the incident, contributing to a lack of proper response.
Victim’s Background and Mental Health Struggles:
Helen Tarry’s partner, Howard Mather, described her increasing paranoia during November and December, exacerbated by the pandemic and the recent death of her father.
Following an overdose, she was voluntarily referred to the Priory Hospital.
CCTV footage showed staff struggling to restrain her on Christmas Day as she attempted to leave the hospital.
Hospital Procedures and Revisions:
The Priory Hospital, previously graded as inadequate by the Care Quality Commission, faced scrutiny for its procedures.
The hospital has since revised its practices, including improvements to staff training, record-keeping, and the installation of mirrors to prevent tailgating through locked doors.
Police Shortcomings and Planned Reforms:
Nottinghamshire Police acknowledged shortcomings in staffing and communication during the incident.
The force plans to introduce formalized procedures to prevent similar miscommunications in the future.
Sergeant James Robinson, who was on shift that night, cited a lack of training for missing crucial details about Tarry’s departure.
Family’s Grief and Legal Proceedings:
Helen Tarry’s partner expressed his grief, describing her as “incredibly humble” and someone who “would always bring light into a room.”
Next month, Priory Healthcare Ltd faces charges under the Health and Social Care Act for exposing another patient, Matthew Caseby, to serious harm at a different facility in Birmingham in 2020.
Conclusion:
The tragic death of Helen Tarry highlights systemic failures in mental health care and police response.
The inquest findings emphasize the need for comprehensive reforms, improved training, and enhanced communication protocols to prevent such incidents and protect vulnerable individuals under mental health care.