A woman killed herself after a south London mental health unit failed to properly search her belongings, a coroner has found.
Michelle Sparman, a personal trainer and Metropolitan Police call dispatcher from Battersea, south-west London, died on 28 August 2021 in Kingston Hospital, four days after attempting to take her own life.
Assistant Coroner Bernard Richmond K.S. concluded that Sparman, 48, died of hypoxic traumatic brain injury, finding that she died as a result of “suicide while the balance of her mind was disturbed, contributed to by neglect.”
He identified four probable causes of death: her struggles with anxiety and depression, including impulsivity; a “complicated relationship” with her ex-partner, including “intemperate and excessive texting” on his part, which called into question her mental health and ability to be a mother; her “justifiable feeling of violence” as a result of his behavior, as well as inadequate searches when leaving and entering Rose Ward, a closed 20-bed women's-only psychiatric unit at Queen Mary's Hospital in Roehampton.
He cited perimenopausal symptoms, as well as financial and professional problems as possible causes.
He said Sparman was admitted voluntarily to inpatient care at Rose Ward with clear “red flags” that she was at risk of harming herself.
He added: “The responsibility to protect anyone on a mental health unit from self-injury with objects seems to me to be a fundamental responsibility of the unit.
“The failure to adequately search is so fundamental that it easily passes the Jamieson test. [a standard of proof for a finding of neglect in an inquest] … She did exactly what she should be guarded against.”
Richmond will also produce a report on preventing future deaths, considering the need for mental health units to introduce a central record of all dangerous items held on the unit, which it plans to submit to NHS England given its potential national implications.
Richmond noted the impact of Sparman's “complicated relationship” with her former partner Roger Stevens, and although he felt that “there was no doubt a lot of love between them”, the relationship took on “a certain toxicity”.
He added that Stevens' messages amounted to harassment and made Sparman feel “trapped”, but he did not believe it was done “intentionally”.
Over five days of evidence in May, the Inner West London Coroner's Court heard how Sparman's mental health deteriorated following the end of her 28-year relationship in January 2020.
In messages sent to her siblings, Sparman said she “might end up taking her own life” because of Stevens' subsequent behavior.
Stevens told Richmond that “in hindsight, I shouldn't have sent so many messages” and agreed they got “very angry” and “put stress on her.”
On August 21, 2021, Sparman was rushed to the hospital after Stevens discovered she had overdosed and harmed herself. Sparman was classified as a “red zone,” meaning she had to be searched for harmful items.
Branch manager Meredith Kuleshnik, who found Sparman, said lessons had been learned, including additional training for staff in search techniques and opening a search room.
While he acknowledged the department was under staffing pressure, Richmond decided the lack of record keeping was a “deeply troubling state of affairs.” Despite evidence that Rose Ward's practices had changed, Richmond said he was not satisfied there was now a “robust recording system”.
Jennifer MacLeod, a solicitor representing the family, cited statistics showing there were 70 incidents of self-harm in Rose Ward in 2020, indicating staff intervened before a suicide attempt could be made.
Kuleshnik also told investigators that she planned to discuss domestic violence with Sparman after observing her interactions with Stevens.
Speaking to talk therapy service Talk Wandsworth, Sparman said Stevens' behavior was “impacting on my sleep, my eating, my confidence, my emotional and mental wellbeing”.
Sean Case, Sparman's half-brother, said she spoke of “anxiety, a tightness in the chest when he [Stephens’] name appeared on her phone” and that she was afraid he would show up at her apartment.
McLeod said: “The family's position is that they perceived it as violence and all the health professionals we heard from perceived it as violence.”
