Cheltenham woman died after 'serious failures' - inquest

A young woman took her own life at a secure psychiatric hospital following "serious failures in communication".

Laura Davis, 22, from Cheltenham in Gloucestershire, died at Arbury Court in Warrington on 20 February, 2017.

Ms Davis, who had been diagnosed with borderline personality disorder, was at Wotton Lawn psychiatric hospital in Gloucester prior to Arbury Court.

On Wednesday, the jury recorded a conclusion of suicide, with her medical cause of death as asphyxia.

During the three-week long inquest, Cheshire Coroner's Court was told Ms Davis, who was admitted to Wotton Lawn in June 2016, had self-harmed extensively while there, had previously attempted suicide and had absconded on multiple occasions.

In November 2016, Ms Davis was moved to Arbury Court, a psychiatric intensive care unit (PICU) run by private provider Elysium Healthcare, when she was deemed to pose a risk to others.

During her inquest, the jury was told information about these suicide attempts was missing from her notes.

In a narrative conclusion, the jury ruled "communication between all parties has been inconsistent" and that record keeping at Arbury Court was "inadequate".

The conclusion stated: "In respect of data transferred from Wotton Lawn to Arbury Court, the data was deficient in showing history of incidents using a household item."

It recorded "a serious failure on communication between staff at all levels" regarding an alleged ligature incident, as well as "a serious failure in not changing the levels of observations" following a suspected ligature.

Ms Davis's mother, Joanna Davis said: "Prior to Laura dying, we had [made] complaints with regards to communication, note keeping, risk assessment, care plans that weren't complete.

The jury also stated there was "an unsafe practice to items of high risk being given out".

Elysium Healthcare - the private provider which runs Arbury Court - said it "apologised unreservedly" for the shortcomings in Ms Davis's care identified during the inquest.

A spokesman described Ms Davis as a "much-loved young woman" and said "important lessons" had been learned and implemented since her death to improve 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," the spokesman added.

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

Her family said she had easy access to dangerous items while in the facility.

"Had [the items] been taken away, we wouldn't be here now," Ms Davis's mother said.

Her medical records stated she had absconded from the hospital 29 times, although Ms Davis's family believe the true figure is significantly higher.

Joanna Davis told the court: "One really important part that hadn't been passed on (to Arbury Court) was the fact Laura had tried to end her life [with a housekeeping item] and she had told me, her step-father and her doctors, that was her preferred method of suicide."

She said she and Ms Davis's step-father, Darren Watts, had told Arbury Court on three occasions a particular item was a serious risk, but this was not communicated to the team caring for her.

"I'm utterly bemused why further protective action was not taken at that stage," Mr Watts said.

A spokeswoman for Gloucestershire Health and Care NHS Foundation Trust said: "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."

Addressing the jury after they had returned their conclusion, coroner Jacqueline Devonish said Wotton Lawn had made 55 recommendations on improving care.

"In light of the measures taken and time elapsed (since Ms Davis' death) I can see no cause to engage a Prevention of Further Deaths Report," she added.

Ms Devonish said: "A great deal of learning has taken place to improve the practices of old and reduce risk of people dying.

"Lessons have most certainly been learned - I hope family can take some condolence from this."

She went on to describe Ms Davis as a "sociable and intelligent young lady who did not like injustice inflicted on herself or others".

And while she had "complex needs", her family worked hard to try and ensure she received the love and support she needed, Ms Devonish added.

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