Bournemouth woman died days after being found in toilet

Emma Victoria Sanders had a “complex” health history with confirmed diagnoses of emotionally unstable personality disorder, PTSD and was known to self-harm.  

An inquest into her death heard that Ms Sanders, 34, had checked into rehab in Cornwall in February 2023 for treatment to a methadone addition and mental health problems. 

Area coroner for Dorset Rachel Griffin said in a report: “During this placement the methadone prescription was reduced more quickly than she had experienced before, and she became emotionally dysregulated.  

“Her mental health deteriorated, and her acts of self harm increased as a result of which she was taken to the local hospital in Cornwall.” 

On March 14, 2023, Ms Sanders was taken to the emergency department at the Royal Bournemouth Hospital after she disclosed that she had taken an overdose of her prescribed medication. 

The inquest heard the hospital at the time was experiencing “extreme capacity pressures” and Ms Sanders was placed in the cohorting corridor which was being staffed by paramedics. 

At 7.53pm, she went to the toilet and 10 minutes later was found in a collapsed and unresponsive condition on the floor of the toilet. 

No staff were in the corridor where she previously was, Mrs Griffin said in a report. 

A spontaneous circulation was found following attempts to resuscitate her before she was placed into the critical care unit. 

But her condition deteriorated, and Ms Sanders died on the March 19, 2023. It has been concluded that she “died as a consequence of the self-application of a ligature to her neck, in circumstances where her intention remains unclear”. 

Mrs Griffin said she has concerns with a delay in accessing a patient’s hospital record and history when taken to hospital by a paramedic. 

She said: “The Summary Care Record does not detail care plans in place for individuals in Dorset, the wider south west region and may be nationally.  

“Lack of access to these plans could impact on patient care and lead to a future death.” 

She has written to South Western Ambulance Service, Dorset Healthcare University, University Hospitals Dorset and the addiction charity We Are With You. 

David Freeman, deputy chief executive of NHS Dorset, said: “On behalf of health and care services in Dorset our thoughts remain with Emma’s friends and family.

"As an integrated care system, we want to thank the corner for her report. We will be considering the findings carefully and responding to the Prevention of Future Deaths report in due course.

“We want to reassure people that we are committed to taking all action possible to prevent such incidents from happening in the future and improving care for communities in Dorset.

“All partners involved in this case have been working with the coroner and a joint action plan was shared in advance of the inquest.

“Further opportunities for learning were identified which we will collectively be taking forward across Dorset.”