Inquest: Neglect healthcare worker asked ‘am I going to go to prison?’ after Hucknall patient found unresponsive

Louise Furlong, 19 – who was a resident Heathcotes Moorgreen care home in Hucknall when she was not in hospital – died on September 12, 2022 after being discovered face-down on the floor of her bathroom at Highbury Hospital in Highbury Vale the evening before.

Sylwia Quaye-Mensah, the woman responsible for the teenager’s intermittent, every-10-minutes observations in the previous hour, is expected to be sentenced for her role in the death on March 2 after pleading guilty to neglect.

The inquest at Nottingham Coroner’s Court saw CCTV footage of Ms Quaye-Mensah sitting in a communal area when she should’ve been outside room 14 on the Rowan 2 ward checking on Miss Furlong.

Between 6 and 7pm on September 11, 2022, there was a 35-minute period when Louise was not checked on at all by Ms Quaye-Mensah, and at 7.09pm, a separate member of staff located her, not breathing and unconscious.

In the immediate aftermath, the inquest heard how a distressed Ms Quaye-Mensah asked Jordan Green, the nurse in charge of the ward that day: “Will I go to prison? What about my daughters?”

Ms Green told the inquest she believed that when Miss Furlong had been on the floor for longer than 10 minutes, and that, having experienced ‘hundreds” of ligature incidents in her career, Louise’s presentation was “different to any patient I’d seen before’.

She said that Miss Furlong was ‘very pale around the neck and that her lips were blue’.

She continued: “I was extremely concerned – it hadn’t just happened.”

Staff raced to Miss Furlong’s aid, started chest compressions and an ambulance was called which eventually took Miss Furlong to hospital.

In the aftermath, Ms Green said that Ms Quaye-Mensah was ‘very anxious and upset’, which the nurse said she initially thought was typical as it was a ‘very traumatic incident’.

Ms Green asked Ms Quaye-Mensah when the last time she’d seen Louise was and said the healthcare worker appeared ‘quite confused’.

She made reference to last seeing her when she ‘retrieved some toast from her bedspace’ but also that she ‘couldn’t remember’ as it ‘all blurred into one’, Ms Green testified.

The nurse suggested they look at the computer tablet on which observations were logged, to jog Ms Quaye-Mensah’s memory, but saw that it had been noted that Louise had been ‘breathing and sleeping’ at times not long before she was found unconscious.

Ms Quaye-Mensah continued to say she could not remember, before, after 10 or 20 minutes of back and forth, asked ‘what if I didn’t check her properly?’ and ‘what if I said I checked her and I didn’t?’

Ms Green said she assured Miss Quaye-Mensah that that wouldn’t be the case and tried to remain impartial that this was somebody ‘very anxious and distressed after what she had witnessed’.

The distress became ‘more evident’ when Ms Quaye-Mensah began to ask about prison and Ms Green eventually sent her home due to the levels of distress becoming ‘quite distracting’.

Ms Green said she had become concerned about what had happened between 6pm and 7pm and later told a co-worker that she thought that the observations may not have been carried out.

The inquest heard that patients on acute psychiatric wards like the ward Miss Furlong was on are often suicidal, but may ligate (tie things around their neck) for reasons other than a genuine attempt on their life, such as to manage emotional pain or to indicate distress.

Miss Furlong had ligated on eight occasions in the five days she had been at Highbury Hospital prior to the fatal incident, and had not made nurses aware by using the emergency alarm in her room, but had been found every time during the intermittent checks.

Ms Green told the inquest that Miss Furlong wasn’t on constant observations for various reasons including that earlier on the day she died, she had been accepting medication, engaging in conversation and talking about being granted leave the next day.

However, it was heard that during a conversation with Ms Green on the day she was found, while distressed, Miss Furlong had also told Ms Green that if she’d ligated, she was ‘frightened she wouldn’t be found’.

After the incident, in a police statement, Ms Green said: “The worst part for me was that, after seeing and knowing Louise, it wasn’t an intentional attempt on her life.

"She would’ve believed someone was coming to check on her within that 10 minute window.”

She told the inquest that she was ‘confident’ that Louise would still be alive if the job had been done properly.

She said: “I strongly believe that Loulou would have expected to have been found.”

The inquest continues.