A PENSIONER found hanging in a mental health hospital had shown signs of distress days before, an inquest has heard.

Staff found Sheila Rusholme, 74, in her room at Bootham Park Hospital, in York, on March 27, last year, with a ligature around her neck, despite being observed every 15 minutes.

The inquest heard how only days earlier she had alarmed staff by injuring herself, but a search of her living accommodation was not carried out.

A Care Quality Commission inspection earlier in 2014, had found “a significant number of ligature risks within the ward environment” and warned that patient safety was at risk.

Workmen from York Hospital’s works department were called in to remove risks, and senior staff and management were tasked with ensuring this was carried out over a number of weeks.

However, Mrs Rusholme, of Bishopthorpe, was found unconscious in her bedroom, and despite efforts of staff and paramedics, she was pronounced dead at the scene.

The first day of a two-day inquest, carried out by Jonathan Leach, York’s acting senior coroner, heard the hospital had been without a permanent consultant psychiatrist for some time, some patient observation sheets were incomplete or missing and healthcare assistants did not receive any formal training to monitor people who were likely to self harm or be suicidal.

Staff instead relied on their decades of experience to look out for patients they thought were at risk.

The court learned that Mrs Rusholme was very private. She rarely spoke to staff but liked to exercise, went out for coffee and attended music recitals with occupational therapists.

She had been admitted after she was visited by community psychiatric staff on March 5, and was looked after by healthcare assistants, staff nurses and doctors while at the facility.

Doctor Faiz-ur Rehman, a locum consultant psychiatrist at Bootham, carried out a number of duties on the ward, meaning he was there for the equivalent of three days a week.

He initially assessed Mrs Rusholme and said the nature of her death had come as a surprise to him.

According to his report, she was very fit and independent, enjoyed seeing friends and going to the cinema, but her self-esteem was not very good.

He said: “(Her death) was a surprise to me. Someone said to me what had happened, and I didn’t think it was Mrs Rusholme. That was my first thought.

“Although there were periods when Mrs Rusholme was distressed and anxious, I feel she was slowly improving.

“I feel her mood and anxiety was not consistently low.

“She was able to gain some pleasure from activities, like going to the gym.”

Anyone with concerns about suicide, or who needs support, can phone The Samaritans on 08457 909090, or Papyrus on 0800 0684141.

*This article has been amended to clarify confusion arising from some misleading points made during the inquest.