Inquest into patient who died at Arbury Court, Winwick

Laura Davis sadly died while detained under the Mental Health Act as a patient at Arbury Court Hospital.

An inquest into her death held at Warrington Coroners’ Court heard how Laura’s 'devastated' family believe she was ‘badly let down’ by the services that were commissioned to protect her life.

Laura, from Cheltenham, had a diagnosis of emotionally unstable personality order and was admitted to Abbey Ward at Wotton Lawn Hospital in Gloucestershire on 24 June 2016.

But she was transferred to the hospital in Winwick, privately run by Elysium Healthcare Ltd and more than 120 miles away, in November 2016 after a suicide attempt and another incident.

In February 2017, Laura was found dead in her room.

Elysium offered its apologies to the family and said lessons had been learned.

The inquest, which took place from January 30 to February 15, heard how On October 10, 2016, while at Wotton Lawn Hospital, Laura’s friend and fellow patient sadly took her own life which ‘particularly affected’ her.

Two days later, she was found by staff in her bedroom with dangerous items – the same items her friend had been in possession of before her death.

Staff suspected Laura had intended to take her own life.

While at Wotton Lawn, which is now run by Gloucestershire Health and Care NHS Foundation Trust, Laura was admitted to A&E 48 times due to self-inflicted injuries.

Laura Davis died at Arbury Court mental health hospital in Winwick

Warrington Coroners’ Court heard how on November 10, a decision was made by the hospital staff to transfer her to a psychiatric intensive care unit after another patient started a fire at the site and staff believed Laura had been involved.

A bed was found in Arbury Court Hospital and within a day, Laura was transferred.

However, the records sent to Arbury Court by Wotton Lawn included nothing about the suspected suicide attempt and the dangerous item she used on October 12, 2016.

The inquest heard evidence that the family provided Arbury Court, on Townfield Lane, with information about Laura’s background and warned staff about the October incident during a meeting with clinical staff on December 13, 2016, due to concerns that they had not been passed all relevant information from Wotton Lawn.

Laura’s family then followed this up with an email sent to staff on December 15. The email included a document on Laura’s risks following her experiences at Wotton Lawn.

However, Laura’s clinical notes were not updated following this meeting or the family’s follow up email and so staff members working with Laura remained unaware of her history.

Laura’s placement at Arbury Court was originally intended to be short-term, but she remained there for over three months due to delays in finding a suitable long-term placement where she could receive appropriate treatment for her condition. 

In the days prior to her death, Laura disclosed to a number of staff members that she was worried about her impending move.

Laura Davis was 'caring' and 'intuitive' 

NICE guidance confirms that for patients with Laura’s condition, transitioning from one hospital to another is a time of increased self-harm and suicide risk.

In the early hours of February 20, 2017, Laura was found crying by a staff member about the death of her fellow patient and friend at Wotton Lawn – but the full background was not known by the worker.

Later that day, staff found Laura in her bedroom and concerns were recorded that she was potentially using dangerous items on two separate occasions.

But neither of these incidents resulted in the dangerous items being removed or staff reviewing Laura’s observation levels which had been reduced to hourly earlier that day.

At 4.42pm, Laura requested an item from the same healthcare assistant and this was given to her after approval from the senior nurse on shift.

At 5.57pm, Laura was found unresponsive in her bedroom and had used the item.

CPR attempts were unsuccessful, and she was sadly pronounced dead shortly after.

She died just days before she was due to be transferred to a new placement to receive specialist treatment for her condition.

Laura’s mother, Joanna Davis, said: “I am devastated by the death of my daughter.

“I feel she was badly let down by the services commissioned to protect her life and that her death was entirely preventable. 

“I am grateful to the jury for recognising the serious failures and deficiencies by both hospitals responsible for her care which caused her death.

“This inquest has been a long and difficult process for our family.

“Despite the serious failures in evidence by hospital staff, we as a family were subjected to the most aggressive questioning of the inquest by the hospitals’ lawyers in an attempt to undermine our credibility.

“No grieving family should have to go through what we went through. 

“I am pleased that despite this, the jury recognised the many failures which led to Laura’s death.”

Senior coroner for Cheshire Coroners’ Court, Jacqueline Devonish, found that Laura took her own life but that a number of failures contribute to her death.

These included:

• The information transferred from Wotton Lawn Hospital to Arbury Court Hospital about Laura was deficient in that it did not include anything about a recent incident where she had self-harmed with the same item as the later fatal self-harm.
• There was inconsistent communication between all parties involved with Laura.
• There was a serious failure of communication between staff at all levels at Arbury Court on February 20, 2017, after Laura was found with a suspected dangerous item and that action could have been taken following this incident.
• Record keeping at Arbury Court Hospital was inadequate, including on the day of Laura’s death.
• There was a serious failure by Arbury Court staff in not changing Laura’s level of observations after she was found with a suspected dangerous item on February 20, 2017.
• There was an unsafe practice at Arbury Court Hospital to items of high risk being given out to patients, in respect of the decision by staff on February 20, 2017, to give Laura the item she used to self-harm. 

Joseph Morgan, solicitor for the family said: “The jury’s strongly critical narrative conclusion exposes the numerous serious failures which caused to Laura’s death by Arbury Court hospital, a privately run hospital using public funds which failed in its duty to ensure Laura’s safety.

“It also acknowledges the role Laura’s local hospital, Wotton Lawn, played in her death. It vindicates the concerns of the family who fought so hard for answers and accountability from both hospitals in the many years since Laura’s tragic death. 

“This case highlights numerous systemic failings within inpatient mental health services, including the failures of privately run hospitals to ensure patient safety, the scarcity of specialist treatment placements for patients with personality disorders and failures in information sharing between institutions.

“These failures are longstanding and endemic, in a system which is underfunded and unfit to ensure patient safety.”

A spokesperson for Elysium Healthcare Ltd said: “We continue to send our deepest condolences to Laura’s family following her tragic death while in our care.

“Laura was a much-loved young woman, and we cannot begin to imagine the grief her family have experienced as a result of her death.

“We apologise unreservedly for the shortcomings identified during the inquest, in terms of the care Laura received while at our hospital.

“In the years following Laura’s death important lessons have been learnt and implemented across all of our hospital sites, and the wider healthcare system, to ensure better communication between providers.

“These changes have better ensured that those individuals in a similar state of mental ill health receive the help and support they require.”

A spokesperson for Gloucestershire Health and Care NHS Foundation Trust added: “We continue to offer our sincere condolences to Laura’s family and everyone who knew her.

“Following her death, we have both carried out our own investigation and participated in other processes, according to national protocols, to establish what more we could have done to prevent this tragedy from taking place.

“All learning from those processes has been incorporated into our trust’s policies and procedures and we are committed to ensuring that we do everything we can to prevent such an event taking place again.”

If you have been affected by the issues raised in this article, or you are struggling with your mental health, help is available.

When life is difficult, Samaritans are here – day or night, 365 days a year.

You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.