Inquest concludes serious failures contributed to self-inflicted death of Beth Tenquist

Following an Inquest lasting 10 days, a jury returned a damning narrative in respect of Sussex NHS Trust and Mill View Psychiatric Hospital, setting out a catalogue of failings by the Trust.

Beth Tenquist was a vulnerable young woman with a raft of mental health difficulties including Emotionally Unstable Personality Disorder, which had developed following years of extreme bullying at school and bulimia. Her conditions were exacerbated by excessive alcohol use. Sadly by June 2017 Beth had developed serious suicidal ideation, and her impulsivity and reckless behaviour was heightened by excessive alcohol use. Throughout 2018 she had multiple admissions to A&E following overdoses and admissions to psychiatric wards. She also self-harmed by cutting and on at least one occasion whilst detained at Mill View Caburn ward, was noted to have self-harmed with the use of a ligature. Her Responsible Clinician, a now retired psychologist, said in evidence that Beth presented the highest level of risk of self-harm that she had ever encountered in her professional career. This was not noted anywhere in Beth's care plan, care notes or known to ward staff or indeed to Beth’s Lead Practitioner or Consultant Psychiatrist.

Beth’s mother Bernadette Tenquist repeatedly expressed her concerns about the ready access to alcohol on Caburn ward, the inconsistent personal and room searches, as well as patients stockpiling and exchanging medication among themselves. Both Beth and her mother also made several complaints about bullying on the ward experienced by Beth at the hands of another patient, as well as an inappropriate sexual relationship with another patient. No safeguarding alerts were raised in respect of any of these matters.

On the afternoon of 29th December 2018 Beth and her mother had a heated exchange with staff over their dismissal of Beth’s complaints about bullying,  which according to another patient, continued that evening. After experiencing the escalating incidents of bullying, Beth secretly brought alcohol onto the ward and drank heavily that evening/night. Her medication was administered by a nurse who failed to breathalyse her, against the requirements of her care plan. Other patients warned staff that Beth had taken an overdose of pills and swallowed glass, one stating to staff that she had witnessed Beth do this. One Health Care Assistant acknowledged that she had been told this by patients and had passed the information onto other medical staff. All other staff that night claimed not to have known about the overdose. Beth’s room was searched and some glass bottles and phone charger cables were removed. However, the nursing staff failed to remove the belt from the dressing gown which Beth was wearing at the time.

Intoxicated on alcohol, possibly unprescribed drugs and having been given her own medication in that state, Beth was left alone, on only intermittent observations every 15 minutes. At some point whilst alone Beth was able to tie a ligature around her neck and hang herself from the back of her bedroom door. She was discovered by a Health Care Assistant who later admitted in evidence that she was not confident in first aid procedures. The observations log suggested that Beth was seen by staff at 23:02, and the evidence from some staff was that she was discovered some 15 minutes later during the intermittent observation. The timeline was not accepted by all staff.

CPR was administered but the ambulance was not called until 23:31. Ambulance staff were told by an unnamed member of staff from Caburn ward that Beth had been seen earlier that night “staggering” along the ward back to her room and had been left alone for 10 minutes. So concerned were the paramedics by that information that they immediately made their own vulnerable persons referral. Both paramedics, including a specialist critical care paramedic who gave evidence, spoke of the importance of the chain of survival and that the sooner that basic life support is administered the greater the chance of survival. In this case, even if staff had reached Beth minutes before, this would have made a difference.

Beth was maintained on life support for a period of time before she died on 16 January 2019.

The jury heard evidence from a large number of key staff and clinicians. They accepted under questioning that staff levels on Caburn ward had reached crisis levels by the end of December 2018 and that at times the ward could not safely meet Beth’s care needs. It was also accepted that there had been a culture of not listening to patients.

The jury returned a short-form conclusion of accident and that at the time Beth did not intend to take her life. They then returned damning narrative conclusions. They found the following probably contributed to Beth’s death:

1. The lack of safety plans for stockpiling of medication, access to alcohol and allegations of bullying.
2. In the hours preceding Beth’s death, the level of her risk of self-harm or suicide was not appropriately assessed by staff.
3. There was inadequate implementation of the risk assessment procedure and poor communication which led to a failure of staff to adequately assess Beth’s exceptionally high risk.
4. The assessment of risk of self-harm was not adequately managed by staff in the following areas:
   (i)         Complaints about bullying were not addressed adequately by staff.
   (ii)        Her ability to access alcohol was not adequately managed.
   (iii)       Her night-time medication was administered whilst she was intoxicated.
   (iv)       Inadequate searching to remove all possible ligatures from her room.
   (v)        Observation levels were inadequate.
5. There was an inadequate system to ensure that patients on Caburn ward did not access alcohol. This was due to:
   (i)         Lack of induction/training of staff in search policy.
   (ii)        Inconsistent implementation of search policy, e.g. daily environmental checks.
   (iii)       Failure to follow-up on intelligence from patients and staff.
   (iv)       Lack of tailored planning for high-risk patients.
6. An inadequate system was in place to ensure that Beth’s room was searched properly and items of self-harm including obvious potential ligatures were removed.
   (i)         Lack of induction/ training of staff in search policy.
   (ii)        Inconsistent implementation of search policy including searching patients.
   (iii)       Lack of record-keeping with regards to room searches including handover sheets.
   (iv)       No clear leadership and accountability with regards to room searches.
7. The inadequate search which failed to identify the ligature which Beth used probably had a direct causal connection to her death.
8. The staff deployment, experience and mix on Caburn ward on the evening of 29th December 2018 was inadequate and led to the following failures which probably had a direct causal connection to Beth’s death:
   (i)         Beth was given her night time medication while suspected of alcohol intake, without being breathalysed by a qualified, registered mental health nurse.
   (ii)        Inadequate room searching by Health Care Assistants who were unfamiliar with the policies.
   (iii)       Lack of a ward manager and a matron led to the inadequate staff deployment that night.
   (iv)       Inexperience and lack of knowledge of Beth’s extremely high-risk, especially whilst intoxicated, led to inadequate observation levels being agreed.
9. The jury considered that the lack of an overarching, dynamic and patient centred care plan led to failures to assess, treat and safeguard Beth Tenquist appropriately and within, this there was a lack of leadership and clarity of roles and responsibilities which probably directly caused her death.

The Assistant Coroner Sean Horstead indicated that he will be making a report to prevent future deaths in relation to the concerns identified:

1. The search policy and Beth’s access to alcohol on a frequent basis. Given the extreme high risk that she was recognised as generating and the evidence known to staff at the time that an even greater elevation of the high risk was occasioned by alcohol; the availability of alcohol was  of critical significance. The PFD letter will specifically address this question.
2. Staff training and auditing. The completion of the handover documents is of concern. The handover from late night shift was chaotic and confused. The paperwork was inadequate. The agency staff was new/only had worked a few shifts on Caburn. The Coroner specifically requires identification of steps to dramatically improve those matters.
3. First aid training for each member of staff to be competent and able to deal with first aid. At least one member of staff did not have these skills even when she gave evidence last week.
4. In respect of the care notes it is accepted by the Trust that Beth’s had not been updated in any meaningful way. The jury’s conclusions in that respect are informative and clear. The Coroner has asked for a detailed response to this point.
5. Staffing level. It was accepted by the unit co-ordinator and the Trust that staffing levels had reached crisis point. There was no ward manager, no matron, a 50% reduction of staff, reliance on bank and agency staff, and low staff morale. A number of members of staff have emphasised that they raised it with managers. Under the refreshed management under lead practitioner nurse, Ms. De Souza, there is optimism that there will be improvements going forward.

After the Inquest, two of Beth’s sisters, Miriam and Alice told ITV news:

“How many more people need to die before proper training is put in place, proper safeguarding is put in place and the evidence showed that there was not for our sister."

"We can’t take any happiness from this verdict because at the moment we’re still just so sad we’ve lost our sister, but we do take some peace in the fact that faults have been recognised and they have to act on them now.”

Basmah Sahib of Bindmans, who is representing the family said: 

“We are extremely grateful to the jury for their diligent attention to the evidence in this case. Although the jury’s findings are in tandem with the candid admissions of the NHS Trust’s witnesses, it is very difficult and sad to hear that Bethany’s death was preventable. We hope that the NHS Trust will address these systemic issues so that the lives of the women on Caburn Ward are protected in future."

The inquest was reported on by the media, including  ITV Meridian News.

Allison Munroe is a member of the Garden Court Chambers Inquests and Inquiries Team.