Two areas of concerns have been raised following an inquest into the death of a mum-of-three receiving care for her mental health.
On Wednesday, the jury returned a conclusion in the inquest of Katarzyna Szymborska, from Newmarket, who died on October 18, 2022.
Mrs Szymborska had struggled with her mental health for many years, dating back to her time in Poland, where she had lived before moving to the UK in 2009.
At the time of her death, the 48-year-old was an inpatient at Wedgwood House in Bury St Edmunds, where she had been since August 17.
Mrs Szymborska had been initially sectioned under Section 2 of the Mental Health Act. From September 9, she remained at Wedgwood House as a voluntary inpatient.
Wedgwood House is located in the grounds of West Suffolk Hospital, but is a separate entity and is run by the Norfolk and Suffolk NHS Foundation Trust.
Previously, the court heard that differences in language had made it difficult for clinicians to support Mrs Szymborska, who struggled to communicate in English without the aid of an interpreter.
On October 14, Mrs Szymborska took action which ended her own life. She died on October 18 in West Suffolk Hospital.
On Wednesday, the jury recorded a narrative conclusion. They found that Mrs Szymborska died from self-inflicted injuries while suffering from depression. They found that her intentions in doing so remain unknown.
Coroner Darren Stewart OBE told the court that he had identified two areas of concern in Mrs Szymborska’s care, although he stressed that these were not causative in her death.
Firstly, he will seek further clarity in the measures NSFT took to ensure that effective communication was enabled between Mrs Szymborska and those treating her.
He also stated that there seemed to have been a “race to discharge” Mrs Szymborska during a meeting held on October 12.
“The court heard plenty of evidence that those processes and key meetings could have been postponed to other occasions when adequate interpretation support was available,” he said.
“None of the staff from NSFT were able to adequately explain why a decision to discharge was required on that day.”
A decision will be made as to whether a prevention of future deaths report is required in November.
The coroner ended proceedings by offering his own condolences to Mrs Szymborska’s daughter, Angelika Szymborska.
He said that her composure and quiet dignity stood as a lasting tribute to her mother’s memory.
“I am sure if she were here today, she would be extraordinarily proud of how you have conducted yourself,” he said.
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