THE DEATH of a depressed psychiatric nurse who jumped in front of a train at Hampden Park level crossing may have been avoided if better NHS systems had been in place, an inquest has heard.
Rosemary Jones, of The Crescent, Newhaven, took her life by jumping in front of a train which was travelling at 70mph through Hampden park station.
The 50-year-old, who had worked as a community psychiatric nurse for around 34 years, suffered ‘catastrophic injuries’ and died at the level crossing on February 12 last year.
Her inquest was held at Eastbourne Magistrates Court on Thursday (February 3) and coroner Alan Craze said there had been a ‘complete failure’ within the NHS systems which had contributed to Mrs Jones’ death.
Mrs Jones had a history of mental health problems and Alan Craze criticised the NHS systems because she was admitted after taking a drug overdose just a few days before she died.
A mental health crisis team, an NHS organisation which operates outside the DGH, was not informed when she discharged herself from A&E.
But since Mrs Jones’ death, steps have been taken to improve communication between the hospital and mental health services.
Mrs Jones’ husband Jeff Harland-Jones, who had been separated from her for around a year at the time of her death, said she had attempted to take her life on at least 10 occasions.
He said, “We tried various things but because Rosie was in the profession, when she was interviewed she knew the answers they were looking for.”
The inquest heard her metal health had worsened after the death of her youngest daughter Louise in March 2008. Her pending divorce was also causing her stress.
Mrs Jones’ daughter Vicky Harland-Jones said she had received abusive text messages from her mother in the final hours of her life. Mrs Jones then went to Vicky’s flat in Hampden Park.
Vicky said, “I was shaking, I was in tears, I was frightened and I hadn’t slept.
“I didn’t let her in but as she left she said, ‘I just want to let you know that I am moving away for good’.”
A concerned Vicky watched her mother drive away from her flat shortly before she took her life.
A number of suicide notes were later found under the driver’s seat of her car which was parked by the level crossing.
Three days earlier Mrs Jones had been admitted to Eastbourne DGH after taking an mixed drug overdose.
She was assessed by mental health professionals and it was decided she would not need to be sectioned but would work with a psychiatric nurse from the crisis team once discharged from hospital.
However, the crisis team were unaware Mrs Jones discharged herself from the A&E ward against medical advice the following day.
The psychiatrists even made a visit to the hospital and attempted to interview someone with the same surname after Mrs Jones had taken her life.
Coroner Alan Craze recorded a verdict of suicide contributed to by system neglect and described the system as ‘amateur’.
He said, “Whatever system was there didn’t work.
“I take the view that if the crisis team had been involved from discharge onwards, there is a far, far better chance that she would still be alive today.
“There was a complete failure through mistakes to monitor her and support her for the 36 hours she was in the community.”
Mr Craze added, “Simply letting her completely drop of the radar was disastrous.”
Daughter Vicky said she felt ‘let down’ by the system.
A spokesperson from the Sussex Partnership NHS Foundation Trust said, “This tragic case illustrates why extremely close working and clear communications are so important between NHS agencies.
“If Sussex Partnership’s mental health team had been alerted to the fact that Rosemary Jones was about to discharge herself from the general hospital (where she was being treated for the physical effects of her overdose) then our mental health team would have attended to carry out a mental health assessment.
“The chances of this situation arising again in the future are small because of the introduction this year of psychiatric liaison services working collaboratively with staff in A&E and general hospital settings so ensuring there are proper communications between ward staff and mental health services.”