Learning from Experience Database - Serious Case Reviews

View Serious Case Reviews by Theme, Local Authority Area or Year

LW (Dorset)

LW was 26 year old woman who had a long and extensive psychiatric history. She had a diagnosis of Borderline Personality Disorder (BPD) although this diagnosis was under review towards the end of her life. She was admitted informally to psychiatric hospital during the night, saying she was low in mood and planning to kill herself. She was detained under section 5 (2) of the Mental Health Act and this was subsequently converted to a section 2 several days later. In the context of LW appearing to be more settled and relaxed, she was allowed two towels and went to take a bath. She was found collapsed in the bathroom twenty five minutes later, with a ligature around her neck and an injury to her head. LW was taken to Dorset County Hospital but never regained consciousness and she died on 28 February 2011.

Professional learning:

  • Improvements needed in the understanding of the wider remit and value of safeguarding adults policies and procedures, across all the agencies.
  • Improvements information sharing and co-ordination of care and support across all agencies including emergency and 24 hours services for the small number of people identified with multiple and highly complex needs, to ensure all relevant agencies can work together effectively and overcome the general and specific difficulties service boundaries create.

2012 SCR regarding LW (Dorset)