Coroner rules lack of mental health beds contributed to death

Seventeen-year-old Sara Green was found asphyxiated on the floor of her room at the Priory Group’s Cheadle Royal Hospital in March last year after what assistant coroner Andrew Bridgman said was a “continuing admission with no soon prospect of discharge”.

The Greater Manchester hospital was more than 100 miles from Sara’s home in Lincolnshire where she was previously treated on an adult mental health ward. She had been considered ready for discharge at the beginning of October 2013 but was still in the hospital five months later.

The coroner said the failure of those responsible for her care to organise her discharge had also contributed to her death.

South Manchester Coroner’s court also heard evidence of significant failings by staff at the hospital, prompting the coroner to write a rule 28 “preventing future deaths” letter to the Priory Group chief executive.

• More news and resources on patient safety

In his narrative verdict Mr Bridgman said Sara’s “prolonged admission” was a consequence of the “inadequate provision” of tier four beds and tier three community placements in the Yorkshire and Humber area. He added that there was “a failure by those engaged in Sara’s care to properly and expeditiously arrange and or manage Sara’s discharge from Cheadle Royal from October 2013 onwards”.

He concluded: “Sara’s continuing admission with no soon prospect of discharge was a contributory factor to her act of self-harm on the evening of 18 March 2014, which ended her life.”

Sara was admitted to the hospital in July 2013 as an out of area placement from the NHS in Lincolnshire due to a shortage of beds. She had a history of mental health problems and self-harm.

Her death followed a letter sent to the hospital by her mother Jane Evans highlighting what she said was “extreme cause for concern” about her daughter’s care.

The inquest heard hospital staff failed to ban items that Sara used in her subsequent suicide despite similar attempts. Staff also did not carry out a risk assessment. The inquest heard the level of observation of Sara by the hospital staff was reduced despite known risk factors, and the company’s policy on observations was not followed.

The coroner’s office told HSJ that the coroner would be writing to the company to express concerns and prevent future deaths.

Deborah Coles, co-director of the organisation INQUEST which has been supporting Sara’s family, said: “The self-inflicted death of a vulnerable teenager in a mental health setting is deeply shocking. Sara was sent to a privately run hospital at great distance from her family because there were no NHS beds available. This highlights the shocking inadequacies in our system of mental healthcare for children and young people that must be urgently addressed by the new government.”

A spokesman for the Priory Group said: “We will carefully consider the concerns raised by the coroner. All staff receive a mandatory level of training. In light of the coroner’s findings, we will review our training and procedures, particularly relating to observations, and make any changes that are necessary.

“Patient safety has always been, and remains, our highest priority, and we are committed to learning lessons to continually improve the services we provide.”

An NHS England spokesman said that following a review of child and adolescent mental health tier four services “immediate action was taken to increase the number of specialised beds; improve case management; and to develop, in conjunction with patients and their families, improved access and discharge arrangements”.

“We know there is more to be done,” he added. “NHS England is working, in partnership with patient representatives, [clinical commissioning groups] and clinical reference groups to ensure that we have the right types of services, delivered at the right time, and in the right place, in order to meet the needs of local populations, thus minimising the distance that patients and their families have to travel to receive appropriate care.”