Kirsty Thain choked to death at psychiatric ward, inquest hears

=Kirsty Thain choked to death at psychiatric ward, inquest hears-tv-Kirsty Thain: https://www.bbc.co.uk/news/uk-england-south-yorkshire-68277437!!bbc,-tv-A woman died after choking on food while under intensive observation at a psychiatric hospital, an inquest heard.-tv-Kirsty Thain, 36, from Wakefield, choked on a chip butty at Kendray Hospital, in Barnsley, in July 2020.-tv-She had been regarded as high risk due to previous attempts to take her own life, including by choking, and staff had been instructed to keep her within arm’s length when she ate.-tv-The hearing at Sheffield’s Medico-Legal Centre is due to last three days.-tv-The inquest heard Mrs Thain had been voluntarily admitted to Fieldhead Hospital at the start of 2019.-tv-Laura Garfoot, of South West Yorkshire Partnership NHS Foundation Trust, said in a statement she had later been detained under the Mental Health Act and was transferred to Kendray Hospital in October 2019.-tv-The inquest was told Mrs Thain had attempted to choke herself on food twice before her death on 9 July 2020.-tv-On both occasions she had been on the highest level of observation and a member of staff had intervened.-tv-The inquest is being held at the Medico-Legal Centre in Sheffield-tv-On the day of her death, the jury was told she had been found trying to hide part of a veggie burger in her clothing and that she had attempted to choke herself twice before she choked on the chip sandwich.-tv-Despite staff trying to dislodge the food and give her CPR, she was pronounced dead by paramedics, the inquest was told.-tv-The court was told Mrs Thain had been involved in about 50 incidents of self-harm or suicide attempts while in hospital, 27 of which happened at Kendray Hospital.-tv-Giving evidence, Det Sgt James Bailey, of South Yorkshire Police, said that on the day she died Mrs Thain had been wrongly given 125mg of pregabalin, five times her prescribed dose.-tv-Side effects of the drug can include suicidal thoughts, he said.-tv-However, he added that she had been seen by a doctor who concluded there had been 'no ill effects' as a result as Mrs Thain had previously been taking up to 400mg a day.-tv-Dr Piyush Prashar, the clinician responsible for Mrs Thain, told the hearing suicidal thoughts were a rare side effect and he did not believe the accidental overdose would have dramatically increased her risk.-tv-The inquest continues.-tv-=Kirsty Thain inquest: Inadequate care contributed to midwife’s death-tv-=Kirsty Thain died by suicide at a Barnsley psychiatric hospital in July 2020, a jury finds. The death of a midwife, who choked while on a psychiatric ward.-tv-Kirsty Thain: https://www.bbc.co.uk/news/uk-england-south-yorkshire-68312119!!bbc,-tv-The death of a midwife, who choked while on a psychiatric ward, was in part due to inadequate care relating to food, an inquest has found.-tv-Kirsty Thain, 36, died after choking on a chip butty while at Kendray Hospital in Barnsley in July 2020.-tv-She had been regarded as high risk due to previous attempts to take her own life, many involving choking.-tv-Returning a verdict of suicide, an inquest jury found there was also 'inadequate assessment around food'.-tv-South West Yorkshire Partnership NHS Foundation Trust said: 'We are very sorry that, in this instance, our care fell short of our usual standards and expectations.'-tv-It said that after Ms Thain’s death it conducted 'a thorough investigation' and had identified ways to improve its care.-tv-The four-day inquest at Sheffield’s Medico-Legal Centre heard how Mrs Thain had been voluntarily admitted to Fieldhead Hospital at the start of 2019.-tv-She was detained under the Mental Health Act and was transferred to Kendray Hospital in October 2019 where she died on the 9 July 2020.-tv-The inquest heard how Mrs Thain, from Wakefield, had told staff she wanted to take her own life and there had been more than 50 incidents of self-harm since she had been admitted to hospital.-tv-On the day of her death, some of her food, including a banana, was cut up to minimise that risk.-tv-However, the chip sandwich was only cut in half, the inquest heard.-tv-Giving evidence, staff nurse Gemma Martin said she was unaware on the day of Mrs Thain’s death that her notes included how food should be cut into smaller pieces for her.-tv-The jury returned a verdict of suicide and said Mrs Thain 'demonstrated a high risk of deliberate self-harm'.-tv-They said there was no care plan around food and there was 'inadequate assessment, communication and mitigation on the ward relating to food'.-tv-Assistant coroner 'Alexandra Pountney' said she had been 'quite impressed' with the measures South West Yorkshire Partnership NHS Foundation Trust had implemented following Mrs Thain’s death.-tv-She said because of this there was no need to prepare a Prevention of Future Deaths report.-tv-The trust added: 'When Kirsty died four years ago we carried out a thorough and immediate investigation and identified ways to improve our care and enhance our service delivery.'-tv-'As a learning trust we continue to work to ensure the services we deliver are the best they can be.'-tv-Mrs Thain, who had worked as a midwife at Leeds General Infirmary, was described by her family as 'a social butterfly', who was the 'life of the party' and 'lived life to the fullest'.-tv-In a statement outside court, her family said some of the evidence at times 'has been harrowing'.-tv-'We have learnt how risk assessments and care plans relating to Kirsty’s inpatient care could have been more robust, which may have prevented the incident that caused Kirsty to die,' they said.-tv-=Defibrillator in wrong mode before Kirsty Thain’s death, inquest hears-tv-=Kirsty Thain, 36, died at a Barnsley psychiatric hospital in July 2020 after choking on food. A defibrillator using the wrong setting had been used on a woman minutes before she went into cardiac arrest, an inquest into her death has heard.-tv-Kirsty Thain’s: https://www.bbc.co.uk/news/uk-england-south-yorkshire-68297574!!bbc,-tv-Staff at a psychiatric hospital in Barnsley had called an ambulance for Kirsty Thain, 36, from Wakefield, after she started choking on 9 July 2020.-tv-They had used the defib in a way which could have given Mrs Thain a shock when her heart was in a 'non-shockable rhythm', a paramedic told the jury.-tv-The inquest will continue on Thursday.-tv-Mrs Thain had voluntarily admitted herself to a psychiatric hospital in Wakefield at the start of 2019, before moving to Kendray Hospital in Barnsley in October of the same year while detained under the Mental Health Act, the inquest had earlier been told.-tv-The court heard how Mrs Thain had a history of attempted chokings before her death.-tv-She had become 'obsessed with ending her own life', assistant coroner Alexandra Pountney said.-tv-The inquest jury was told that on the day of her death, Mrs Thain had started choking on a chip butty.-tv-She was moved to her bedroom where first aid, including two shocks from a defibrillator, was given by staff.-tv-Paramedic Wayne Corbett, from Yorkshire Ambulance Service, told the inquest that when he arrived at the scene, he removed 'two large pieces of bread' from Mrs Thain’s airway using forceps.-tv-After confirming she had a pulse despite not being responsive, he identified her heart was 'in a non-shockable rhythm' and started performing CPR.-tv-It was only after Mrs Thain was declared dead 40 minutes later and the defibrillator had printed out a summary of events that Mr Corbett realised the machine was in another mode and had already delivered two shocks.-tv-He explained to the inquest jury that the defibrillator 'can be put into another mode where the machine will read what heart rhythm the service user is in and it will advise you to carry CPR'.-tv-'Does that mean that those two shocks may have been given against an un-shockable rhythm, we just don’t know?' Ms Pountney asked.-tv-Mr Corbett said that was correct, adding that giving the shocks could lead to 'further complications' and 'could hinder the outcome' with the patient.-tv-The inquest into Mrs Thain’s death is expected to conclude on Thursday.-tv-