Coroner Finds Neglect Contributed to Death of Woman Who Took Her Life Following Hospital Admission
LONDON – A coroner has ruled that neglect contributed to the death of Sarah Sparman, 55, who died by suicide in August 2021 after being admitted to Rose Ward at Springfield Hospital in south London. The inquest, heard at Inner West London Coroner’s Court in May, revealed critical failings in the ward’s record-keeping of potentially dangerous items and a lack of robust search procedures despite Sparman being designated a “red zone” patient – indicating a high risk of self-harm.
Coroner Richard Richmond concluded that the absence of a centralised record of dangerous items on the ward was “a profoundly worrying state of affairs.” He noted that despite evidence suggesting changes to ward practices, he was not satisfied a “robust recording system” was currently in place. He plans to submit a report to NHS England outlining the need for a national implementation of such a system, given the potential for wider impact.
The inquest detailed how Sparman’s mental health substantially deteriorated following the breakdown of her 28-year relationship with Roger Stephens in January 2020. Texts to her siblings revealed she feared she “could end up killing myself” due to Stephens’ subsequent behavior. Stephens himself acknowledged “in hindsight I should not have sent so many texts,” admitting they were “very angry” and “put stress on her.”
On August 21, 2021, Stephens discovered Sparman after an overdose and self-harm, leading to her hospitalisation. Despite her “red zone” status requiring searches for harmful items, the inquest highlighted deficiencies in this process. Ward manager Meredith Kuleshnyk, who found Sparman, stated that lessons had been learned, including increased staff training and the creation of a dedicated search room.
Evidence presented showed a high incidence of self-harm on Rose Ward, with 70 recorded instances in 2020 alone, indicating frequent staff intervention to prevent suicide attempts.
The coroner also heard testimony regarding the impact of Sparman’s “tough relationship” with Stephens, described as having gained a “certain toxicity” despite “a great deal of love” between them. Richmond noted Stephens’ messaging constituted harassment, leaving Sparman feeling “trapped,” though he did not believe this was intentional. Sparman herself reported Stephens’ behaviour had negatively impacted her “sleep, my eating, my confidence, my emotional and mental wellbeing” in a self-referral to Talk Wandsworth. her half-brother, Shaun Case, described her experiencing “anxiety, tightness in her chest” when Stephens’ name appeared on her phone and fearing he would visit her flat.
Jennifer MacLeod, representing the family, stated that sparman perceived Stephens’ behaviour as abuse, a view shared by medical professionals who testified. Kuleshnyk also indicated she intended to discuss domestic abuse with Sparman following observations of her interactions with Stephens.
If you are struggling with suicidal thoughts, please reach out for help. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org. In Australia, the crisis support service Lifeline is 13 11 14. other international helplines can be found at befrienders.org.
