Michelle Sparman, 48, ended her own life when she should have been safe in hospital
Michelle Sparman died in August 2021 after a voluntary admission to Queen Mary’s Hospital(Image: fitsw11/Instagram)
A woman who felt like she was being abused by her ex took her own life after a South London psychiatric unit failed to properly search her things, a coroner has concluded. Michelle Sparman, 48-year-old a personal trainer and call dispatcher for the Metropolitan Police, died on August 28 2021 at Kingston hospital, four days after tying a ligature at Queen Mary’s hospital in Roehampton.
Assistant Coroner Bernard Richmond KC, concluded that Sparman, of Battersea, died of a hypoxic brain injury, having attempted suicide “whilst the balance of her mind was disturbed, contributed to by neglect” after self-admitting as a voluntary in-patient on Rose Ward, a locked 20-bed female-only mental health unit.
The probable causes of her decision, included: struggles with anxiety, depression, and impulsiveness; a “difficult relationship” with her ex-partner, including “intemperate and excessive texting” from him, which called into question her mental health and fitness to be a mother; her “justifiable feelings of abuse” as a result of his behaviour; and inadequate searching on leaving and entering the ward.
Michelle’s family with members of the Southall Black Sisters(Image: SBS)
“The duty to protect someone in a mental health ward from injuring themself with items seems to me to be a fundamental obligation of the ward,” said Richmond, adding: “The failure to search adequately is so fundamental, it easily passes the Jamieson test [a standard of proof for a finding of neglect in an inquest] … She did precisely the thing she should have been guarded against.”
Richmond will write a prevention of future deaths report looking at a need for mental health wards to introduce a centralised record of all dangerous items that are on the ward, which he plans to submit to NHS England given its potential national implications.
Richmond noted the impact of Sparman’s “difficult relationship” with her ex-partner Roger Stephens, and though he felt there was “no doubt a great deal of love between them”, the relationship developed a “certain toxicity”.
Stephens admitted he sent too many texts while giving evidence, but Richmond concluded he had not done so “deliberately”. In texts sent to her siblings however, Sparman said she could “end up killing myself” over her former partner’s behaviour.
Jennifer MacLeod said: “The family’s position is that she perceived that as abuse, and all the medical professionals we have heard from perceived that as abuse.” Shaun Case, Sparman’s half-brother, said she spoke of “anxiety, tightness in her chest when his [Stephens’] name came up on her phone”, and that she feared him turning up at her flat.
Roger Stephens said he ‘cared deeply’ for Michelle and did not deliberately harm her(Image: Roger Stephens)
On August 21 2021, Sparman was taken to hospital after Stephens found she had taken an overdose and self-harmed. Sparman was categorised red, meaning she was supposed to be searched for harmful items. Ward manager Meredith Kuleshnyk, who found Sparman, said lessons had been learned since her death.
Although he acknowledged the staffing pressures the ward was under, Richmond determined that the absence of record-keeping was “a profoundly worrying state of affairs”. Despite evidence suggesting Rose Ward’s practices had changed, Richmond said he was not satisfied that a “robust recording system” was now in place.
After the inquest concluded Stephens said: “I met Michelle in our early 20s. We built our lives together and raised two beautiful children in a loving home. I cared deeply for her. Our relationship unfortunately broke down and at times we both did not behave as we should have.
“But the coroner determined after hearing all the evidence that I did not do anything deliberately to harm Michelle. The coroner did not find that I abused her. There were numerous pressures on Michelle at the time of her death.
“I loved her and I still do, as do my children, and we wish that she was with us today. This process has been very difficult for me and my children, and I look forward to putting it behind us.”
Bernard Richmond KC concluded Michelle Sparman’s death was contributed to by neglect(Image: Lamb Building)
Hannana Siddiqui, Director of Policy, Campaigns and Research at Southall Black Sisters said: “We welcome the Assistant Coroner’s recognition that Michelle’s suicide resulted from a state of mind in which she felt she was being subjected to domestic abuse and due to neglect from the NHS psychiatric ward.
“This is a landmark decision as it is one of a handful of cases in which the link between suicide and domestic abuse has been explicitly recognised, especially in relation to a Black, minoritised, and migrantwoman. We believe it will aid in preventing suicides and in holding perpetrators to account.
“The police had previously failed to investigate Michelle’s death as a possible criminal offence, and we now call on them and the Crown Prosecution Service to review the case.”
Frank Mullane, CEO of Advocacy After Fatal Domestic Abuse said, “Michelle Sparman felt ‘trapped’ by the domestic abuse she was experiencing. This was a finding from the inquest which concluded that Michelle’s view that she suffered abuse was justifiable and that this was one of four probable causes of death.
“The family and multiple medical professionals also concluded that Michelle suffered domestic abuse. It is fitting that more coroners are beginning to see and understand the links between domestic abuse and suicide.”
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