THE DECISION to downgrade a hospital patient’s observation levels and neglect contributed to her death, an inquest found.

A jury found that Sarah Price took her own life on February 2, 2016, while a patient at St Cadoc’s Hospital in Caerleon.

Miss Price’s observation levels were lowered by staff on the day of her death from constant observation to 15-minute check-ins.

Ahead of that decision, Miss Price had told staff that she “was not sure she could keep herself safe”.

However, staff agreed that on that day, Miss Price appeared “brighter” and “had a light in her eye”, and that she would be able to spend time on leave to visit her family, should her observation level be lowered.

Miss Price was discovered by staff at around 1.40pm, and after attempts were made to resuscitate her, she was pronounced dead at 2.24pm.

Miss Price’s family have campaigned on her behalf for five years, and, after the conclusion of her inquest, said justice had “finally been done”.

“The jury have found that the decision to reduce Sarah’s observation was a gross failing by the Aneurin Bevan health board and that this allowed Sarah to be able to take her own life,” said Rachel Price, Sarah’s mother.

“Sarah was profoundly let down by Aneurin Bevan health board when she was most in need.

“We would like to thank the jury and our legal team. We have fought for justice for Sarah for five long years, and justice has finally been done.”


The jury returned a narrative conclusion.

“On February 2, 2016, Sarah took her own life,” they said. “Despite the actions of the staff, Sarah could not be revived and died at 2.24pm.

“On February 2, 2016, staff downgraded her observation levels from level three to level two without fully taking in to account Sarah's risks of self-harm.

“Sarah's death was contributed by neglect.”

South Wales Argus: Sarah Price, who died at St Cadoc's Hospital in February 2016. Picture: Family photo.Sarah Price, who died at St Cadoc's Hospital in February 2016. Picture: Family photo.

Miss Price had been admitted to St Cadoc’s Hospital in Caerleon in November 2015, having attempted to take her own life in the supported living accommodation she had been living in.

Summing up, senior coroner for Gwent Caroline Saunders said: “Sarah Price was a 23-year-old woman who struggled with her mental health since childhood.

“Sarah was suffering with emotionally unstable personality disorder overlaid with depression and anxiety.

“Sarah’s admission was different to previous admissions. She was flat; she did not engage.

“Sarah told staff and her parents that she intended to leave the ward and take her own life.”

Miss Price absconded from the ward multiple times while at St Cadoc’s, and on one occasion was stopped from taking her own life by a member of the public.

In the two weeks leading up to her death, Miss Price attempted to abscond six times, but was prevented by staff from doing so.

Miss Price also attempted to take her own life twice in that time – on January 24 and 26 – and was prevented by staff from doing so again on January 29.

Miss Price’s observation levels were lowered on the day of her death from level three to level two.

Over the three days of evidence, staff at the hospital were asked why potentially dangerous items were not removed from the ward.

Ms Saunders said she was satisfied that consideration had been given to removing the potentially dangerous items.

“It was taken to senior management,” she said. “It was given that they could not be removed due to health and safety reasons.”

A spokeswoman for Aneurin Bevan University Health Board said: “Our thoughts are with Sarah’s family at this difficult time.

“The health board conducted a thorough Serious Incident investigation into the care Sarah received in St Cadoc’s Hospital in 2016 and the findings have been shared fully and openly.

“The health board took corrective actions at the time of the incident and following the investigation and we acknowledge the outcome of the inquest.”

Miss Price’s medical cause of death was recorded as 1A: asphyxiation; 1B: Carbon dioxide poisoning; 1C: Breathing in to a restricted space; and 2: Cerebral Palsy and depression.