A hospital neglected a vulnerable woman who accidentally killed herself in a part of the building bosses had been warned could be used for hanging, an inquest has concluded.

Deirdre Harvey, known as Dee, was found dead at Royal Glamorgan hospital on 10 April 2017.

She had been detained several weeks previously under the 1983 Mental Health Act, an inquest at Pontypridd coroner’s court heard.

Eighteen months before she was found hanged, Healthcare Inspectorate Wales had raised concerns about ligature points with Cwm Taf University health board, which runs the hospital.



In August 2016, following a further review of ligature points on its mental health wards, ordered by the Welsh government, the health board identified the point from which Harvey would later kill herself as a potential ligature point that needed removing or redesigning, the inquest jury was told.

No adaptations were made before her death.

Harvey had been in and out of hospital for several months before she died, and had bipolar disorder, paranoid beliefs and very low mood.

She had tried to kill herself before and told staff she did “not regret what she did and wished that she had been successful in ending her own life”, the inquest heard.

Throughout January and early February 2017, her mood remained low and she said she wanted to kill herself.

But an inquest jury on Friday concluded her eventual death was an accident contributed to by neglect.

It also found she was insufficiently monitored on the day she died, and that the hospital had failed to remove the ligature point despite knowing of its existence.

The jury also found that an underestimation of Harvey’s mental illness by staff may have contributed to her death, along with a failure to appropriately medicate her psychiatric problems.

Harvey’s daughter Rebecca, 22, said: “Mam was such a loving and caring person, who doted on her family.

“We hoped that in hospital she would receive the care and support she needed to get better, so she could return to her family; instead she was failed by those who were supposed to help her.

“Our family has been left devastated by mam’s death, which we now know was contributed to by neglect and a series of failings. It has been very difficult to hear how the hospital knew about the exact ligature point my mum used for seven months before her death and didn’t remove it.”

The coroner, CJ Woolley, said he would write to the Welsh government to raise concerns that future deaths may arise from the apparent lack of a system for making urgent funds available to health boards to address dangerous hospital environments.

Gus Silverman, a public law and human rights lawyer at Irwin Mitchell, representing the family, said after the inquest: “It is a matter of particular concern that as long ago as October 2015, Health Inspectorate Wales had raised an ‘immediate concern’ regarding ligature points and audits at the Royal Glamorgan hospital.

“It is now imperative that mental health wards throughout the country give urgent consideration to whether they are providing a safe environment for their patients.”

Deborah Cole of the campaign group Inquest said she hoped the “catastrophic health and safety failures” would result in the hospital being prosecuted for health and safety breaches.