Before Area Coroner Sonia Hayes
Essex Coroner’s Court, Seax House, Victoria Road South, Chelmsford, Essex, CM1 1LX
12 June 2023 – 23 June 2023
Edwige Nsilu died aged 20 while detained under the Mental Health Act 1983 as an inpatient at Colne Ward, St Andrew’s Healthcare Essex. She died on 5 February 2020 at Basildon University Hospital, after being found unresponsive with multiple ligatures around her neck on Colne Ward at St Andrew’s on 3 February 2020.
The inquest into Edwige’s death found she died by misadventure contributed to by neglect with the following failures contributing to her death:
- Inadequate design and completion of observation forms
- Insufficient interaction with patients when carrying out observations
- Inadequate updates of Edwige’s care plan after 8 January 2020
- Failure to increase Edwige’s observation intervals despite recent escalation of serious incidents relating to Edwidge’s behaviour and deterioration of Edwige’s mental health
- Inadequate record keeping
- Serious delay in declaring a medical emergency for Edwige
- Unacceptable delay in delivering Basic and Immediate Life Support for Edwige
- Unacceptable delay in notifying emergency services
Edwige Nsilu was born and raised in Walthamstow in London. Her parents were from the Democratic Republic of Congo and raised her to speak their native language of Lingala as well as English. The inquest heard how she liked to listen to music, had a strong affinity for her Congolese background and culture and was well-liked by staff and patients on Colne Ward.
Background to the case
The inquest heard evidence that Edwige found the transition to Colne ward difficult, and that there were frequent incidents of self-harm and aggression in the months following her admission, which included tying ligatures and punching herself in the face. However, after several months of unsettled behaviour, she was able to turn a corner in the summer of 2019. Motivated by the goal of returning home to her family after many years away, she worked hard to engage with the therapy available on the ward and this led to a period where she was settled and stable from August to December 2019.
As a result of the excellent progress she had made, she was granted unescorted leave by St Andrew’s to return to the family home on several occasions around Christmas and New Year over December 2019. However, the inquest heard that after she returned to the ward in January 2020 she experienced a deterioration in her condition.
Multiple incidents of self-harm were recorded in her patient records over January 2020, including multiple ligature incidents. The inquest heard how staff responded to Edwige’s increased risk by increasing level of observations to intermittent 15-minute observations on 13 January 2020. However Edwige’s care plan had not been updated since 7 January 2020.
Edwige’s self-harm continued to increase in both frequency and severity over the course of January and into February 2020 – on 21 January she was placed in seclusion after punching herself in the face and tying a ligature, and then becoming aggressive with staff; on 23 January a medical emergency was called when she tied a ligature and lost consciousness briefly; on 26 January she used strips of a torn towel to tie a ligature; on 27 January 2020 she ligatured again with strips torn from a towel. At this point, Edwige was already supposed to be nursed in strong clothing and without unsupervised access to the bathroom. Despite Edwige’s risk not being contained on the current plan, it remained unchanged.
On 2 February 2020, Edwige was discovered to have given another patient items which they went on to use to self-harm, including a ligature. She expressed remorse to staff about this, but then later that night she was discovered to have tied a ligature with a bath towel.
Despite the above incidents, by 3 February 2020 St Andrew’s plan to manage Edwige’s risk of self-harm had not changed from 15-minute observations, keeping her in rip-proof clothing and with a sterile bedroom. It was open to staff to increase Edwige’s observation levels to ten minutes, five minutes or constant 1:1 observations to manage her level of risk. There was no record of any discussion or review by clinicians of Edwige’s risk and whether her observation levels should be increased. In fact, her observations remained at 15 minutes on 3 February 2020.
The inquest heard how responsibility for carrying out Edwige’s 15-minute observations on 3 February 2020 was handed over to a healthcare assistant. Edwige spent 13 hours asleep in the Extra Care Suite from midnight on 3 February. Nobody had any meaningful interaction with Edwige, she was not reviewed by a doctor, nor was there any assessment of her mental state following the incident the night before. The healthcare assistant responsible for Edwige’s observations recorded them up until 3.30pm, when she was called off the ward to deal with another incident. Her evidence was that she would have handed over responsibility for Edwige’s observations to a nurse on the ward, but no nurse accepted that they had taken over responsibility for Edwige’s observations.
The inquest heard that Edwige was found by a senior nurse at 3.55pm lying on the floor on the bedroom doorway with three ligatures around her neck. He removed two ligatures by hand and with the help of a second nurse the third ligature was removed by ligature cutters. The nurse who found Edwige gave evidence that he initially believed Edwige was feigning unconsciousness as a means of luring staff before attacking them. There was no evidence that Edwige had ever feigned unconsciousness in order to attack staff. Instead of immediately commencing CPR, the inquest heard how the first nurse left Edwige with the second nurse to find an oximeter to measure her pulse, only for the second nurse to leave her on the floor to deal with another incident. The first nurse returned with an oximeter which he applied to several fingers and failed to get a reading. He then called for help and asked a third nurse to get a blood pressure machine which they used on Edwige, but failed to get a reading of her blood pressure. The inquest heard evidence from an expert paramedic, who made clear that there was no reasonable justification for the actions of the nurses who found Edwige unresponsive.
The inquest heard that a medical emergency was called at 4.03pm, and by 4.05pm a physical healthcare assistant arrived on the ward and initiated CPR. An ambulance was called at 4.08pm by the third nurse. The ambulance arrived and Edwige was taken into intensive care at Basildon University Hospital but unfortunately it was found that she had not made a neurological recovery. On 5 February 2020 doctors informed the family that Edwige had suffered a hypoxic brain injury that she would not recover from. They made the difficult decision to end life support and she died in Basildon University Hospital that day.
Edwige’s mother, Joyce Nsilu said:
We loved Edwige very much. She was loving, warm, nurturing, gorgeous and strong. We called her the mother of all children because she had a deep love for every single person. Everyday feels like a dream because she was such a blessing to our family, but I know that one day, with God’s grace, we will see her again. Edwige will always be our daughter, big sister, and aunt. She never got to meet her nieces and nephews but we will always remind them and future ones of who she was.
We miss her dearly and will never stop wondering what could have been different.
Rest my child and know that mummy loves you too forever.
Joseph Morgan, solicitor at Bindmans LLP representing Edwige’s family, said:
The jury’s conclusion is utterly damning. St Andrew’s failed in their most basic duty to ensure Edwige’s safety. The evidence heard during this inquest about the multitude of failures in Edwige’s care has been harrowing and shocking. It paints a picture of a unit that was unsafe for patients, with tragic consequences for Edwige. This case highlights many of the reoccurring systemic failures within inpatient mental health care, including a failure to appreciate the seriousness of self-harm attempts, overwhelmed staff ill-equipped to care for vulnerable patients, a lack of leadership and oversight. These failures are endemic in a system bursting at the seams and putting the most vulnerable patients at risk.
The family were represented by Joseph Morgan of Bindmans LLP as solicitor, and Kirsten Sjøvoll of Matrix Chambers as counsel.