NURSES at the Countess of Chester Hospital have come under fire after a sick pensioner in their care took an overdose.
Geoffrey Lyon had warned staff to watch his mother Dorothy after finding an empty bottle of paracetamol in her handbag.
This week, deputy coroner for Cheshire, Dr Janet Napier, said it was 'regrettable' nursing staff did not register this warning and act upon it.
'Although it is likely that by that time, it would have been too late to save Mrs Lyon,' she added.
An inquest on Wednesday heard that Mrs Lyon, of Parklands Drive, Elton, died of liver failure as a result of her overdose on Sunday, October 20, 2002.
It is not known exactly when the 77-year-old took the tablets during her week-long stay at the hospital where she was being treated for a heart condition.
Mr Lyon told the court that his mother appeared to be recovering days before her death but then suddenly had a relapse.
He said: 'She was due to come out of hospital. She was going back to her bungalow and social services had worked out a home-help package for her.
'But on the Thursday before her death she called me at about 9.30pm and said she was not happy. She said she was all on her own and wanted to kill herself.
'After calling me, she phoned a friend to say the same thing. This friend then called me at home before ringing the hospital to tell them.'
The following day, Mr Lyon, of Manley View, Elton, visited his mother and found the paracetamol bottle when she asked him to go into her bag for her glasses.
'My wife and I went outside to talk because we did not know what to make of it. I suspected she had taken them.
'I said to a nurse, 'I hope you are going to check her for paracetamol because I think she has taken some,' and then we went home.'
Mr Lyon said his mother had made suicide threats before. 'We did not take her seriously,' he said. 'She would joke that she was going to walk on the motorway, but it was her Lancashire sense of humour.'
On Saturday, October 20, Mrs Lyon's condition deteriorated rapidly. She slipped into unconsciousness and became hypothermic.
When test results showing high levels of paracetamol in her system came back, Mrs Lyon had already died.
The retired legal secretary's former colleague and friend of 20 years, Maureen Jones, said Mrs Lyon had called her moments after putting the phone down from her son on Thursday, October 17.
She said: 'She didn't want to be a burden to her family. She said she wasn't ready to come home. I rang her son and then called the hospital.
'I didn't tell them that she had threatened to kill herself. I just told them to keep an eye on her because she was very upset.' Mr Lyon and Mrs Jones both told the court that Mrs Lyon was very 'medically aware' and knew her ill-ness would only get worse.
Ward manager Diane Reeves said: 'It is routine to ask patients if they have any medication with them. But if they say no we do not have the rights to search their belongings.
'I have spoken to the nurse who recollects speaking to Mr Lyon about the possibility his mother took paracetamol. But there is no record of that conversation.'
Dr Napier said: 'It is difficult because nurses do not have the rights to search a patient's bag. It is difficult to balance human rights and privacy with safety.
'It was very unpredictable, not least because Mrs Lyon was known for not wanting to take tablets that might harm her.
'Her son had found the empty bottle and came to the right conclusion about what she had done and so told a nurse. Unfortunately, that nurse did not register it and notice was apparently not taken.
'It is a very sad situation but it was Mrs Lyon's choice. She was a lady who liked to make her own choices about things.'