Neglect Led to South London Woman’s Death in Psychiatric Ward

A coroner has found that a South London mental health unit failed to properly search a patient’s belongings, contributing to her death after she took her own life. Michelle Sparman, a 48-year-old personal trainer and Metropolitan Police call handler, died on August 28, 2021 at Kingston Hospital. Four days earlier, she tied a ligature while voluntarily admitted to Rose Ward — a secure, 20-bed women’s psychiatric unit at Queen Mary’s Hospital in Roehampton.

Assistant Coroner Bernard Richmond KC concluded that Sparman died from a hypoxic brain injury after attempting suicide “while the balance of her mind was disturbed,” with neglect playing a role. Sparman had admitted herself to the ward amid severe anxiety, depression, impulsiveness, and distress connected to a difficult relationship with her ex-partner. Richmond said her perception of abuse was “justifiable,” and that constant, overwhelming messages from her ex raised questions about her mental state and ability to parent.

He ruled that staff failed in their basic duty to protect her, noting that searches when entering and leaving the ward were inadequate. The lack of proper procedures was serious enough to meet the Jamieson criteria for neglect. Richmond stressed that Sparman died in the very manner staff should have prevented.

Richmond said he would issue a prevention of future deaths report, recommending that all mental health wards keep a centralised log of potentially dangerous items. He intends to send the report to NHS England due to its wider implications.

The coroner also highlighted the damaging nature of Sparman’s relationship with her former partner, Roger Stephens. Although he acknowledged there was “a great deal of love,” he said the relationship eventually became “toxic.” Stephens admitted that he sent too many messages, but Richmond accepted he had not acted with deliberate intent. Nonetheless, Sparman wrote to her siblings that his behaviour made her feel she might “end up killing myself.”

Family members said Sparman experienced significant anxiety whenever Stephens contacted her and feared him showing up at her home. On August 21, 2021, after Stephens discovered she had overdosed and self-harmed, she was taken to hospital and given a red risk rating, requiring searches for harmful items — a safeguard staff failed to apply properly. Ward manager Meredith Kuleshnyk said the team has learned lessons since her death.

Despite acknowledging staffing shortages, Richmond said the absence of consistent documentation of dangerous items was “profoundly worrying.” While the ward claims to have updated its procedures, he remained unconvinced that the system is now “robust.”

After the inquest, Stephens said he and Sparman had built a life together and raised two children, and that her death has deeply affected the family. He stressed the coroner found he had not intentionally caused her harm, saying he hopes to move forward after a painful process.

Hannana Siddiqui of Southall Black Sisters welcomed the coroner’s acknowledgment that Sparman’s mental state was shaped by her experience of domestic abuse and failures in the NHS system. She called the decision significant, particularly for Black, minoritised, and migrant women, and urged police and the CPS to review the case.

Frank Mullane, CEO of Advocacy After Fatal Domestic Abuse, said Sparman felt “trapped” by abuse. The inquest recognised that her belief she was being abused was justified and that this was among the main factors contributing to her death. He said it is encouraging that more coroners are recognising the connection between domestic abuse and suicide.