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Priory mental health patient, 52, walked out of ‘secure’ ward by tailgating staff member nine hours before she was found dead on farmland, inquest hears


A mental health patient was found dead on farmland – nine hours after walking out of a ‘secure’ Priory hospital ward on Christmas Day.

An inquest heard council worker Helen Tarry tailgated a staff member through two doors, one of which was usually locked, before pressing a fire alarm and running outside into the car park of the hospital at Arnold, Nottingham.

The 52-year-old’s body was found by a dog walker on land next to a track on Boxing Day morning in 2022.

Failings by the hospital and police led to her death, the inquest found.

Returning a conclusion of misadventure with a narrative verdict on Tuesday, jurors at Nottingham Coroner’s Court said there were communication failures from all parties, inadequate risk management, missed opportunities to mitigate absconsion risk and insufficient senior oversight’.

Helen Tarry's body  was found by a dog walker on land next to a track on Boxing Day morning in 2022

Helen Tarry’s body  was found by a dog walker on land next to a track on Boxing Day morning in 2022

Ms Tarry tailgated a staff member through two doors, one of which was usually locked, before pressing a fire alarm and running outside into the car park of the hospital at Arnold, Nottingham. Pictured: Nottingham Priory

Ms Tarry tailgated a staff member through two doors, one of which was usually locked, before pressing a fire alarm and running outside into the car park of the hospital at Arnold, Nottingham. Pictured: Nottingham Priory 

Jurors also ruled there had been ‘inadequate and confusing record-keeping, missed opportunities to escalate the situation from all parties and a lack of understanding of proper policy and the failure to follow policies that were in place’.

Nottinghamshire Police, which did not dispatch officers to the scene after being notified of Ms Tarry’s absconding, also admitted ‘missed opportunities’ during the inquest.

Ms Tarry’s partner Howard Mather told the court how his partner of ten years had become ‘increasingly paranoid’ throughout November and December of that year. He said the pandemic and the recent death of her father had further impacted her mental health.

He described how Ms Tarry, a system support officer for Nottinghamshire County Council, had started to shred paperwork and hide items around their house before eventually moving in with her mum. She also became convinced her phone had been hacked and called police on several occasions.

She was voluntarily referred to the Priory Hospital after being taken to Kings Mill Hospital, Mansfield, following an overdose of paracetamol.

CCTV from earlier on Christmas Day showed staff at the hospital holding Ms Tarry back as she moved towards the ward’s exit.

Ms Tarry ran out of the hospital at 10.18pm and was wearing just a nightdress, slippers and gilet. She was found early the next morning without the gilet or slippers, with one of the slippers later found further down the farm track.

Failings by the hospital and police led to her death, the inquest found. Pictured: Nottingham Priory

Failings by the hospital and police led to her death, the inquest found. Pictured: Nottingham Priory 

Post-mortem examinations determined that while hypothermia and a cold-induced asthma attack were both possible, the exact cause of her death could not be determined.

Nottinghamshire Police – under fire this week after it emerged officers had shared details of the injuries suffered by the victim of triple killer Valdo Calocane in a shift WhatsApp group – should have had a minimum of one inspector, one sergeant, and 12 PCs on the ‘extremely busy night’, the inquest heard.

However, only one inspector, one sergeant and seven PCs were working that night.

Sergeant James Robinson, who was on shift on the night in question, had only been in his role since September 2022 and ‘had a lack of training to do my job’.

Sergeant Robinson told Coroner Fiona Gingell that he missed some details about the circumstances under which Ms Tarry went AWOL (absent without official leave) from the ward.

This included the fact that she was barefoot and that she was not wearing a coat, despite temperatures between 2C and 8C that night.

Procedures at the hospital, which has been graded as inadequate by the Care Quality Commission, have been revised, including improvements to staff training and record keeping, the court was told.

Mirrors have also been installed to help prevent the tailgating of staff through locked doors.

Nottinghamshire Police said it planned to introduce formalised procedures to prevent similar miscommunications between call handlers and operational staff in future.

Mr Mather said he had been planning to marry his ‘incredibly humble’ partner, who ‘would always bring light into a room’.

Next month Priory Healthcare Ltd will answer a charge under the Health and Social Care Act for exposing personal trainer Matthew Caseby to serious risk of harm while he was a patient at the Woodbourne Priory hospital in Birmingham in 2020. The penalty is an unlimited fine.

Mr Caseby was hit by a train within days of being admitted to the hospital, following his detention by police under the Mental Health Act.

In 2022 an inquest jury found the 23-year-old’s death was contributed by neglect after hearing how he was left unattended in a courtyard for five minutes, allowing him to scale a 7ft 6in fence.



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