A senior coroner has questioned how a nurse was able to do two jobs at once with the pressures he was under as the inquest into a “caring and sensitive” 16-year-old continued.

It comes as the inquest into the death of Evelin Chacko of Colchester Drive, Farnworth, at Bolton Coroners' Court heard evidence on Wednesday that she was on an “inappropriate” ward.

The “talented” student was found dead in woodland near the Royal Bolton Hospital on July 13, 2020, after being admitted on July 1, 2020, following an overdose.

On July 13, nurse Afreen Khan was in charge of the ward Evelin was on, as well as the named nurse for nine other patients.

At the inquest on Thursday, he said: “You shouldn’t be a named nurse and in charge, but we were expected to do both roles because of the pandemic and staffing.

“I didn’t have the chance to sit down and read her notes.

“I gave her medication, carried out observations and saw her behaviour.”

Area Coroner Professor Dr Alan Walsh said: “At the age of 16, with some vulnerabilities on an inappropriate ward, she possibly should have had extra contact to check she was okay.

“I am concerned about the pressure on the likes of Mr Khan as to whether he can do the job as the nurse in charge of the ward and the named nurse in charge of the other patients.

“I want to make sure it doesn’t happen again.”

Mr Khan said that during a meeting on July 10, 2020 that he was awaiting a mental health review for Evelin, but that the next steps would be dealt with by another team.

Mr Khan says he was not aware that Evelin attempted to harm herself the night before her death during the handover.

The inquest also heard that a mental health review took place on July 13 at around 1pm, but Mr Khan was not able to attend due to the pressures he was experiencing.

Staff nurse Mary Hart was on various shifts throughout Evelin’s time in the hospital, and she had no concerns about Evelin, apart from when she noticed she was upset on July 13.

Ms Hart said: “On July 13 Evelin walked past and she appeared to be very upset, and it was out of character for her.

“She was crying.

“I did speak to her, but she wouldn’t engage or acknowledge me.

"When nurse Dawn Murphy came back from the Clinical Decision Unit she said she met security at the entrance and gave Evelin's name and description."

It was heard that notes completed in the electronic system at 1.49pm stated that there was a “need to monitor” Evelin, but Ms Hart was not aware of the contents of this.

Evelin had left the hospital at 2.12pm on July 13 before she died.

A spokesperson for Oakwood Solicitors on behalf of the family said: "Oakwood Solicitors are deeply saddened by Evelin Chacko’s tragic death however, we are consoled with the admissions made by Bolton NHS Foundation Trust in relation to their failings.

"The investigations are still underway with regards to the involvement of Greater Manchester Mental Health and Bolton Council, but it has been recognised that Evelin, a 16-year-old, was on a wholly inappropriate adult acute ward. "There is a lot to learn from the death of Evelin.

"The nurse involved in Evelin's care admitted that they did not have time to review the records and she was inappropriately placed on a ward where they were not experienced to deal with Evelin's mental health.
"What was consistent is that Evelin was loving and caring.

"It is hoped that when the investigations resume in the Autumn that the family will be able to receive some closure."

The inquest has now been adjourned until October 30 where more evidence will be heard.

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