A WOMAN was found dead in a nearby stream on the day she left a rehabilitation clinic against medical advice.
An inquest on Suzanne Rixham, from Shotton, who died aged 45 in February 2015, heard she was being treated for addiction at the Hafan Wen rehabilitation clinic run by charity CAIS at Wrexham Maelor Hospital.
North Wales East and Central coroner John Gittins concluded her death was accidental and the cause was methadone and mirtazapine poisoning.
Ms Rixham had admitted herself to the clinic on February 10 for a course of detoxification to treat an addiction to alcohol and a methadone script she had been taking.
The hearing in Ruthin also heard she was on a long term course of anti-depressant mirtazapine at the time of her treatment.
However during the night of February 12, 2015 and into the early hours of the following morning, Ms Rixham became agitated and started insisting she did not want to stay for the treatment any longer.
Mental health nurse Andrew Smith told the inquest he was one of the people caring for Ms Rixham from the point she was admitted on February 10 and was on duty the night of February 12-13.
Mr Smith said: “When I first saw her she was quite focused and wanting to complete her detox.
“After a couple of days, she wanted to go early which she first voiced to me on the evening of February 12.”
Mr Smith told the inquest Ms Rixham had appeared anxious and agitated, but he and his colleagues had tried to persuade her as best as they could that staying was the better option. He also said the two-hourly check-ups that were scheduled for all patients were increased to every half an hour for Ms Rixham that night.
In the early hours of February 13 Ms Rixham repeated her request to leave and Mr Smith arranged a meeting with Dr Shichao Sun, on duty senior health officer (SHO), to try to persuade her otherwise.
Dr Sun told the coroner she had reiterated her concerns to Ms Rixham that leaving that early could have serious health consequences for her, but carried out a ‘capacity assessment’ to assess whether Ms Rixham was capable of making her own decision about whether she wanted to leave or not.
Dr Sun said her assessment, backed up by a second opinion from her colleague, showed she did have the capacity to make the decision despite it not being in her best interests.
After the meeting with Dr Sun, Mr Smith said it seemed like Ms Rixham would agree to stay, but within a few minutes of her leaving she remained adamant that she wanted to go and she left shortly after 5am.
Shortly after Mr Smith left work that morning, he and his colleague saw Ms Rixham walking along the opposite side of the road near the clinic, prompting his colleague to call Amy Ashworth, the current nurse on duty, to tell her that the patient had been seen walking and had not got the train home as she had allegedly stated was her intention.
In a statement read to the inquest, she said she and her colleague called the police who began to coordinate a search throughout the day.
Ms Rixham’s body was found by PC George Job, who discovered her face down in a stream adjacent to Hafan Wen that evening.
A post-mortem examination conducted by pathologist Dr Mark Atkinson found there were no injuries on Ms Rixham’s body or alcohol in her system, but that there was a fatal level of both methadone and mirtazapine.
A report from Det Insp Ian Verburg noted the search for Ms Rixham throughout February 13 could have been rationalised and coordinated better and that training programmes for new officers had been updated to reflect that.
Similarly, the co-author of a report into the incident by Betsi Cadwaladr University Health Board (BCUHB) found the incident had raised questions about the way records are kept by staff, adding their training programmes for junior doctors had also been updated accordingly.