The death of a mental health patient who swallowed an eight-inch table knife was a tragic case of misadventure, a jury has ruled.

Suzanne Johnston was a sectioned patient at Sturdee Community Hospital, in Eyres Monsell, Leicester, where she was being treated for an 'emotionally unstable personality disorder' and helped to manage her behaviour.

The 41-year-old died at Leicester Royal Infirmary on March 9 this year - two months after she had first told staff at the community hospital that she had swallowed the blade.

After hearing two days of evidence and one day's deliberation, a jury at Leicester Coroner's Court, in the Town Hall, returned a verdict of "death by misadventure" yesterday.

Addressing the court, the jury's foreman said: "Our conclusion in this inquest into the death of Suzanne Johnson is one of misadventure."

He gave the medical cause of death as "multiple organ failure" caused by sepsis, in turn caused by a "self-inflicted gastric perforation" to her stomach wall which led to a fistula - where bile entered from her digestive system entered her lungs.

The jury ruled that this was, in turn, caused by her personality disorder.

Suzanne Johnston
Suzanne Johnston

Assistant coroner Dianne Hocking described a verdict of misadventure as a "deliberate human act which unexpectedly and unintentionally causes death".

Summing up the evidence, she said that Ms Johnston was a "vulnerable lady" who moved Sturdee Community Hospital, which is a rehabilitation unit in Runcorn Road for people with mental health issues and personality disorders, from a more secure mental health hospital in October 2016.

Hospital staff and psychiatrists testified during the inquest that Ms Johnston displayed "attention seeking, exaggerated and sensationalising" behaviour.

Mrs Hocking said this resulted in her "wanting things there and then" and, if she didn't get her way she would "behave badly towards others".

The court heard that her behaviour would include making false allegations and claims, and that she had a history of self-harming and swallowing things, but had not done so for the previous four years.

Ms Johnston had reported to staff that she had swallowed a knife on January 4, however, tests carried out by paramedics found no evidence of this and she later changed her mind.

Mrs Hocking said that, at a staff meeting to discuss the matter the following day, the deceased reiterated her claim, however, changed her story once again when she was told Sturdee Hospital would "not be the place for her as a high risk patient".

The court heard that on Ms Johnston had been eating and sleeping well and, on February 3, had gone out with staff and eaten pizza.

But, on February 13, she attended the hospital GP, unaccompanied, complaining of "wheezing" where she reiterated her claim of having swallowed a knife.

Despite a physical examination finding no signs of this, she was given a referral to go to hospital to have an X-ray, however, she did not attend this appointment and failed to inform Sturdee staff about the referral.

The coroner's office is based at the Town Hall in Leicester

An X-ray was carried out at Leicester Royal Infirmary on February 20 after she developed signs of a chest infection, which revealed the tip of a knife which was removed by surgeons two days later.

Dr Robert Williams, the consultant surgeon who carried out the operation described the metal blade as being "blackened" by stomach acids, adding that it could have been inside Ms Johnston’s stomach for several weeks.

Her respiratory problems continued to worsen and, too unwell for further surgery, she went into multiple organ failure on March 8 and died the next day.

Albert Chelliah, group operations director at InMind Healthcare Group, which runs Sturdee hospital, told the inquest that protocols have been tightened up - to ensure X-rays are given whenever a patient claims to have swallowed a foreign body, and improve communication between GPs and hospital staff.