Lack of Mental Health Care Contributing to an Increase In Patient Deaths

An Essex Coroner has warned, whilst giving her conclusion at the inquest of teenager Morgan-Rose Hart, that there will be more deaths unless mental health services quickly improve for those with autism and at risk of self-harm.

Inquest touching the death of Morgan-Rose Hart

Morgan-Rose Hart, from Chelmsford, had a diagnosis of ADHD and autism. She also had a well-documented history of mental health illness, having experienced multiple admissions to hospital whilst detained under the Mental Health Act 1983 from 2020 onwards.

Shortly after her 18^th birthday, Morgan-Rose was admitted as an inpatient to Chelmer Ward in Harlow, Essex in July 2022. Morgan required constant observations on admission, due to her high risk of self-harm which included a history of ligaturing. On 6 July 2022, a vision-based patient monitoring system (using cameras) notified staff that Morgan-Rose was going to take a shower. This was a recognised blind spot and risk area in patients’ rooms on the ward. However, the alert was reset by staff without performing any physical check of Morgan-Rose, despite the hospital’s policy mandating this. Morgan-Rose was sadly found unresponsive in her bathroom more than 50 minutes later, having self-ligatured. She sadly passed away on 12 July 2022 due to her injuries.

A jury inquest was heard by Area Coroner for Essex, Ms Sonia Hayes. The jury found that Morgan-Rose died from a hypoxic ischaemic brain injury and cardiac arrest. These injuries were caused by ligature contributed to by neglect.

The evidence given during the course of the inquest showed how critical observations of Morgan-Rose were missed. Observation levels were reduced from constant to hourly and observations were falsified by staff in her records. Among various other failures, staff failed to remove risk items from Morgan-Rose at any time during her 3-weeks on Chelmer Ward. There were also failures to conduct adequate risk assessments, and sadly, to simply engage with Morgan-Rose in a meaningful therapeutic manner throughout her admission.

The Coroner subsequently made a Prevention of Future Deaths report addressed to Essex Partnership University NHS Foundation Trust (‘EPUT’) and Essex County Council, stating:

Ms Hayes listed a number of areas of concern in respect of EPUT, including but not limited to:

In relation to Essex County Council, Ms Hayes stated that:

EPUT has since reacted to the report along with the Essex County Council.

A spokesperson for EPUT commented:

Prevention of Future Deaths Reports

Legislation imposes on Coroners a duty to make reports to a person, organisation, local authority, or government department where it is believed that action should be taken to prevent future deaths when concerns have been raised during the inquest process. This is known as a Prevention of Future Deaths Report or a ‘Regulation 28’ Report.

Simply put, the impact of these reports can be powerful. These reports place, on those it is addressed to, a duty to respond in writing within 56 days to detail action taken (or proposed action) to address each area of concern directly.

Prevention of Future Deaths Reports (and sometimes the written responses) are published online. This means that whilst these reports are not inherently intended to penalise those it is addressed to, the potential reputational damage is significant.

Comment

It is very concerning to see that EPUT has once again been found to have failed its patients; a hospital trust which has already been scrutinised by the Care Quality Commission and faced criminal prosecution for failing to manage risks from fixed ligature points at its mental health wards, resulting in a fine of £1,500,000.

Worryingly, this trust is also subject to an independent statutory inquiry relating to the deaths of individuals in unexpected, unexplained, or self-inflicted circumstances over a 20-year period. A catalogue of deaths have been linked to mental health services provided in Essex.

Repeated failures in care point to deep-rooted systemic issues at the trust as well as a much wider crisis in mental health care across the region. Clearly, lessons are yet to be learned in order to effect real change.

However, it is hoped that the failures recently identified by the Coroner in Morgan-Rose’s care and the duty placed on EPUT to adequately respond to the Coroner’s report will be the catalyst needed to prevent further shortcomings in care in similar circumstances. The trust must now take action to ensure that its own written policies and procedures are properly embedded into everyday practice across the board.