Stephen Clark of the Garden Court Chambers Inquest Team represented the family. Stephen was instructed by Catherine Shannon of Bhatt Murphy solicitors.
An inquest jury has found that serious failures of risk assessment, communication, and the setting of observation levels contributed to the death of 19-year-old Brooke Martin on 11 June 2019.
Brooke, who had diagnoses of Autism and Emotionally Unstable Personality Disorder, was detained under the Mental Health Act at Chadwick Lodge Hospital run by Elysium Healthcare when she died. Brooke, described as a caring, thoughtful and clever young woman by her family, had a chronic history of life-threatening self-harm.
Reaching their conclusion, the jury found that Elysium Healthcare failed to properly manage Brooke’s risk, identifying factors contributing to her death as:
- The failure of staff to communicate information regarding an incident five days prior to her death when Brooke was found suspended from a ligature in her room;
- The failure of staff to search Brooke’s room after she was found handling potential ligatures on the night she died;
- The failure of staff to increase Brooke’s level of observations to constant observations when she was found handling potential ligatures on the night she died.
Brooke, from Godalming in Surrey, was found unresponsive by staff on the evening of 10 June 2019 having suspended herself from a ligature in her hospital bedroom; she was later pronounced dead at Milton Keynes University Hospital.
The inquest heard that earlier that evening Brooke was twice found by staff to be handling an item that could be used as a ligature which she had concealed under her duvet. The staff members failed to re-assess Brooke’s risk, to place her on constant observations, or to search her room for potential ligatures in response.
Evidence was heard that Brooke had previously suspended herself from a ligature only five days earlier on 5 June 2019. It was accepted by healthcare witnesses that this incident was a ‘massive red flag’ and an ‘alarm’. However, it was not properly recorded or communicated between staff and as a result did not trigger a risk assessment or review of Brooke’s observations.
The inquest heard that the ward was ‘chaotic’ on 5 June 2019, when four serious incidents occurred simultaneously. At the Multi-Disciplinary Team meeting the following day it was not communicated that Brooke had applied a suspended ligature. Further, a ‘glitch’ affecting the computer system meant that the record of this incident was not available to staff within Brooke’s medical records. As a result staff treating Brooke on the day of her death were unaware that this earlier incident had taken place.
On the day of her death, Brooke presented as overwhelmed and distressed. However, this information was not handed over from the day to the night staff.
Elysium formally admitted during the inquest that when Brooke was twice found with potential ligatures on the night of her death these should have been removed from her, a risk assessment conducted, and Brooke placed on constant observations. Elysium accepted that had this action been taken Brooke would not have died. Elysium further accepted that, following the incident on 5 June 2019, Brooke’s risk should have been re-assessed and information about the incident communicated to staff treating her.
The inquest jury concluded that Brooke took her own life while suffering from a mental illness, namely Emotionally Unstable Personality Disorder.
The coroner confirmed that he would write a report, intended to prevent future deaths, to the Secretary of State for Health and Social Care concerning inadequacies in the systems in place for the sharing of medical records between healthcare providers. He confirmed that he would also raise the issue of the introduction of anti-ligature pressure sensors in mental health settings at the Milton Keynes Together multi-agency safeguarding group and with other coroners nationwide.
Brooke had begun to experience mental illness in her early teenage years. Her mental health deteriorated markedly during the 18 months prior to her death, resulting in numerous serious incidents of self-harm and periods of detention under the Mental Health Act. The inquest heard that the severity of Brooke’s self-harming was such that between April 2018 and February 2019 she required medical treatment at one local A&E department on 39 separate occasions.
Between December 2018 and April 2019 Brooke was detained for treatment at Farnham Road Hospital in Guildford, which is run by Surrey and Borders Partnership NHS Foundation Trust. In April 2019, Brooke was transferred to Chadwick Lodge Hospital. The inquest heard that although during her first month at Chadwick Lodge Brooke had found it difficult to settle, she was showing a ‘remarkable’ improvement by the time of her death.
A referral was being progressed for her to move to Hope House, a separate unit within the same hospital that delivers specialist therapy to treat Emotionally Unstable Personality Disorder. During the days before her death Brooke, whose long-term ambition was to become a vet, told staff that she was eager to move to Hope House and engage in the therapy offered there.
Natasha Darbon, Brooke’s mother, said:
“Brooke was a kind, clever woman and my best friend. I feel so incredibly sad that she is no longer here. As a family, we did our best to keep Brooke safe in the community, but eventually the risk she would harm herself became too much for us to cope with. We thought it was a positive step when Brooke was admitted to hospital because she would finally receive the help she needed, and in the meantime, she would be kept safe by professionals with the necessary expertise.
As a family we have been utterly shocked to learn of the inadequacies in the care provided to Brooke at Chadwick Lodge, and that opportunities to save her life were repeatedly missed by those entrusted with her care. I would like to thank the coroner and the jury for considering the evidence. I sincerely hope that lessons will be learned so that no other family has to lose a loved one in such tragic circumstances.”
Paul Martin, Brooke’s grandfather, said:
"Brooke wasn't just a hospital reference number or a statistic, she was a much-loved daughter and granddaughter. Not only has a generous spirit been lost but my opportunity to have great-grandchildren. The unjust nature of her death is totally unacceptable. Despite her illness, she was fighting to get better and move on to Hope House. The phrase ‘missed opportunity’ doesn’t do justice to the seriousness of the failures. I write this not just for myself but for all families that have to endure such injustice and the loss of loved ones in these circumstances. Lessons desperately need to be learned.”
Catherine Shannon of Bhatt Murphy solicitors and Stephen Clark of Garden Court Chambers, who represent the family, said:
“Brooke was detained under Section 3 of the Mental Health Act when she died; she had a chronic history of life-threatening self-harm. This inquest has revealed stark failures in risk assessment, information sharing and observation setting in a mental health hospital dealing with an exceptionally vulnerable patient group.”
This press release was first published on INQUEST's website on 1 July 2021.
