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Coroner left ^baffled^ by hospital oversights

A catalogue of failures by mental health workers may have led to an Eastbourne poet hurling herself in front of a train, an inquest heard on Tuesday (May 24).

Staff on Eastbourne DGH^s psychiatric ward refused to take inpatient Irene Hoggan back into care despite being rushed to hospital after allegedly overdosing on 200 pills to treat her diabetes.

The following day 56-year-old Ms Hoggan threw herself into the path of a 70mph train at Hampden Park railway station.

Coroner Alan Craze was baffled by the oversights of hospital admission ^gatekeepers^. He said, ^You had a patient with a long history of suicidal intentions, of actual suicide attempts, a degree of mental illness, a patient who has been in hospital on many occasions, for four months prior to going on leave. You have got a patient who has allegedly tried to commit suicide that morning and been brought by an ambulance to A&E and asked to see mental health, a patient who has actually walked around to say, ^please let me back in^, escorted back to A&E and then absconded, and nobody thinks of calling the police?!^

Mr Craze said he was considering a verdict of suicide contributed to by neglect, but said he needed more information from Sussex Partnership Trust, which runs mental health services across Sussex.

Psychiatric staff had tried to wean published poet Ms Hoggan off direct hospital support. She was put on temporary leave for the first time just two days before she died.

After spending two nights at her home in St Annes Road, paramedics brought Ms Hoggan into Eastbourne DGH claiming she had overdosed on a year^s worth of drugs. She was told to wait in A&E to be assessed by the Crisis team, while they saw to other patients.

In a desperate attempt to get readmitted she walked 700 yards to the Bodiam Ward and asked a nurse if he would take her back.

She was told her bed had been given to someone else and there was no room for her.

Ms Hoggan was escorted back to A&E where she waited for almost four hours to be tended to before leaving.

Psychiatric staff said she was a ^low risk^ patient.

The following day Ms Hoggan got a taxi to Beachy Head and then Hampden Park railway station where she threw herself onto the tracks on February 21, 2009.

In a statement read out in court, train driver Nicholas Baumann said, ^In my opinion the lady was absolutely determined to take her life. She was completely focused in what she was doing.^

Registered mental health nurses asked police to check up on Ms Hoggan more than hour after she had died. Ann Hewitt of the Crisis team admitted not calling the police earlier had been a mistake.

A spokesman for the Trust said, ^This was a tragic incident and our sympathies go to the family. We have investigated extremely thoroughly how this came to happen and we will take full account of the conclusions to be reached by the coroner. This took place over two years ago and services have changed much since then. These include new services to provide support to people in crisis and a new hospital liaison service which works extremely closely with the DGH, and a new integrated in-patient crisis service led by a single clinical team.^

Mr Craze adjourned the case for six weeks while the Trust gathers more information.