Michelle Morton: EPUT mental health failure had 'catastrophic' result
John Fairhall/BBCMultiple failings in the care of a young woman at a mental health facility had "catastrophic consequences", an inquest jury has concluded.
Michelle Morton was an inpatient at The Lakes in Colchester, Essex, when she died in December 2019.
Area coroner for Essex Sean Horstead said the jury's findings were "profoundly important".
The Essex Partnership University NHS Foundation Trust (EPUT) said safety was its "absolute priority".
Ms Morton's sister, Joanna Morton, said: "My little sister was failed by those who should have kept her safe.
"The care Michelle received from EPUT was substandard and the trust must learn lessons from her death."
Family handout
Ms Morton, who worked as a horse groom, had a diagnosis of emotionally unstable personality disorder but was described by her sister as a happy girl growing up who was a "brilliant mother".
Chelmsford coroner's court heard it was a "very busy" night at The Lakes on 8 December 2019, with one healthcare assistant attending five different incidents.
A ward manager told the court Ms Morton should have been observed at the point she walked out of an unlocked lounge and into an unlit garden.
Ms Morton was later found unresponsive in the garden and staff and paramedics tried to resuscitate her.
John Fairhall/BBC
John Fairhall/BBCThere was a risk assessment detailing ligature risks for staff to read, but a senior nurse in charge of the ward, Jane Biner, told the inquest she "wasn't aware of the ligature risk" in the garden and "couldn't remember reading the assessment" despite signing her name to say she had.
In its narrative, open verdict, the jury highlighted:
- A failure to perform health and safety checks
- A lack of observations and communication, not taking into account Ms Morton's condition
- Inadequate staffing levels, below those authorised by the Trust
Mr Horstead said "remorseless observation" was needed in areas with potential ligature risks.
He said on this occasion, such observation "did not happen with, in the jury's words, catastrophic consequences".
Family handoutThe health trust was fined £1.5m last year over the deaths of 11 patients between 2004 and 2015.
After the hearing Ms Morton's mother Angela said: 'I'm angry because it should never, ever, have happened."
Michael, her father, said: "The lessons are not being learned. They haven't been learned for ages and how many more people are going to die before things are really dealt with?"
Bereaved families stood outside the court as part of their campaign to upgrade an ongoing independent review, to a statutory inquiry.
The health trust said it had invested £20m to make wards safer in recent years.
In a statement, a trust spokesperson said: "Safety is our absolute priority and we are relentlessly focused on providing the best care and support for patients in environments that are both safe and therapeutic.
"We have made significant investment to improve safety on our wards and reduce the risk of self-harm, and are committed to continuously improving the care we provide."
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