The Oxleas NHS Foundation Trust has admitted liability for the death of Diana Mager on 08 August 2012.
Mrs Mager was suffering from severe post-natal depression having given birth to her daughter Sofia in November 2011. Mrs Mager was suffering from chronic anxiety and delusions and she began to self-harm. She was admitted to Green Parks House psychiatric unit in Orpington, Kent as a voluntary patient in June 2012 but her husband, Adam Mager, was concerned that she did not have a proper care plan.
Mrs Mager was initially admitted on 'one to one observations', but following an improvement in her symptoms, her observations were reduced and she was allowed supervised and unsupervised leave from the unit. On the first occasion she was allowed unsupervised leave, supposedly for no more than 30 minutes, she in fact proceeded to the Tate Modern gallery where she tried to jump from the members' gallery roof terrace on the fifth floor. Luckily a member of the public pulled her back from the edge and saved her life.
In spite of this incident, Mrs Mager was not put back on one to one observations.
Over the course of the next week Mrs Mager's condition deteriorated. On one occasion when she was allowed home leave, she tried to run away from the family home. On another occasion she managed to smuggle a sharp, serrated kitchen knife into the unit, and on a further occasion tried to abscond from the unit itself. In spite of all of these events, and the facts that her medical records included an entry that "Diana is at very high risk of killing herself" she was only observed at 15 minute intervals.
In the very early hours of 08 August 2012 Mrs Mager took her own life.
During the inquest into the death of Mrs Mager, the Trust contended that Mrs Mager's death "could not have been predicted or prevented". However after Court proceedings were served on them, they admitted liability, acknowledging that Diana's death could and should have been prevented.
"I am pleased to see that liability has finally been admitted by the Trust in this matter. I am however concerned that the admission comes after the Trust had initially claimed, following a full and through investigation, that Diana's death could not have been predicted or prevented. There needs to be far greater transparency and honesty in mental health care in this Country if the public are to have confidence in the system, especially at a time when the mental health service in this country is reported to be in crisis."
Adam Mager added:
"I always believed that Diana would be alive today if she had received the proper care she desperately needed. Instead, I have to explain to our daughter why her mother is no longer with us."
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