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NHS staff watched woman die on CCTV because they presumed she was sleeping

Trust admits ‘shortcomings’ after Shannara Donnelly, who needed continuous ‘one-to-one’ care, lay unresponsive for over an hour

Shannara Donnelly was meant to be watched 'within eyesight' at all times, the inquest heard
Shannara Donnelly was meant to be watched ‘within eyesight’ at all times, the inquest heard Credit: Donnelly family/SWNS

NHS hospital staff watched a dying woman lie unresponsive on the floor for over an hour because they thought she was sleeping, an inquest has heard.

Shannara Donnelly, 22, was meant to be watched within eyesight “at all times” because she was considered at risk of self-harm, North London Coroner’s Court was told.

However, medical staff watching her through CCTV cameras missed her collapsing to the floor in her room at the?Chase Farm Hospital in Enfield, north London, the inquest heard.

It was said that when nurses saw her on the ground they presumed she was sleeping, and that she lay unresponsive for over an hour.

The inquest, which is expected to last up to two weeks, heard Donnelly died “apparently [by] her own hands”.

Medical staff watching Ms Donnelly through CCTV cameras missed her collapsing to the floor in her room?at Chase Farm Hospital
Medical staff watching Ms Donnelly through CCTV cameras missed her collapsing to the floor in her room?at Chase Farm Hospital Credit: Fela Sanu/iStock Editorial

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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