Before HM Senior Coroner Jacqueline Devonish
Cheshire Coroner’s Court
30 January – 17 February 2023
Laura Davis died aged 22 whilst detained under the Mental Health Act as a patient at Arbury Court Hospital in Warrington, run by Elysium Healthcare Ltd.
The inquest into Laura’s death found she died by suicide with the following failures contributing to her death:
- The information transferred from Wotton Lawn Hospital to Arbury Court Hospital about Laura was deficient, in that it did not include anything about a recent incident where she had placed a plastic bag over her head.
- There was inconsistent communication between all parties involved with Laura.
- There was a serious failure of communication between staff at all levels at Arbury Court on 20 February 2017 after Laura was found with a suspected ligature, and that actions could have been taken following this incident.
- Record keeping at Arbury Court Hospital was inadequate, including on the day of Laura’s death following the above ligature incident.
- There was a serious failure by Arbury Court staff in not changing Laura’s level of observations after she was found with a suspected ligature on 20 February 2017.
- There was an unsafe practice at Arbury Court Hospital regarding items of high risk being given out to patients, in respect of the decision by staff on 20 February 2017 to give Laura a plastic bag.
Laura was from Cheltenham in Gloucestershire. Her family describe her as caring and intuitive, and someone who always put others before herself. She was a hard-working and high achieving student who had ambitions to become an RAF officer.
Laura had a diagnosis of emotionally unstable personality disorder, was a victim of sexual assault and had a history of serious self-harm. She was admitted to Abbey Ward at Wotton Lawn Hospital in Gloucestershire on 24 June 2016, after which she was detained under the Mental Health Act.
The inquest heard evidence that Laura was particularly affected by the self-inflicted death of her friend and fellow patient at Wotton Lawn on 10 October 2016. Two days later, Laura was found by staff in her bedroom with a plastic bag over her head and a ligature round her neck which was the method her friend had used to take her own life. This incident was described as a ‘copycat’ incident in Laura’s clinical notes and the staff suspected that Laura had genuinely intended to take her own life on that occasion.
On 10 November 2016, a decision was made by Wotton Lawn staff to transfer Laura to a psychiatric intensive care unit after another patient started a fire in the hospital and staff believed Laura had been involved. A bed was found in Arbury Court Hospital, a privately run hospital in Warrington over 120 miles away, and within a day she was transferred. However, the records sent to Arbury Court by Wotton Lawn included nothing about the suspected suicide attempt using a plastic bag on 12 October 2016.
The inquest heard evidence that the family provided Arbury Court with information about Laura’s background during a meeting with clinical staff on 13 December 2016, due to concerns that they had not been passed all relevant information from Wotton Lawn. This included warning staff about the 12 October 2016 incident whereby Laura had used a plastic bag and ligature. This was followed up with an email sent by the family to staff on 15 December 2016 attaching a document on Laura’s risks which referred to her risk of ‘suffocation’ following experiences at Wotton Lawn. However, Laura’s clinical notes were not updated following this meeting, nor the family’s follow up email, and so staff members working with Laura remained unaware of her history.
Laura’s placement at Arbury Court was originally intended to be short-term, but she remained there for over three months due to delays in finding a suitable long-term placement where she could receive appropriate treatment for her condition.
In the days prior to her death, Laura disclosed to a number of staff members that she was worried about her impending move. NICE guidance confirms that for patients with Laura’s condition, transitioning from one hospital to another is a time of increased self-harm and suicide risk.
In the early hours of 20 February 2017, Laura was found crying by a staff member about the death of her fellow patient at Wotton Lawn, but the full background was not known by that staff member. Later that day, staff found Laura in her bedroom with pyjama bottoms over the door of her bathroom and concerns were recorded that they were being used as a ligature. Then, at 4:27pm, a healthcare assistant saw Laura in her bedroom and noticed she had tied knotted pyjamas on her bedroom door. Neither of these incidents resulted in the suspected ligatures being removed or staff reviewing Laura’s observation levels which had been reduced to hourly earlier that day.
At 4:42pm, Laura requested a plastic laundry bag from the same healthcare assistant and this was given to her after approval from the senior nurse on shift. At 5:57pm, Laura was found unresponsive in her bedroom with a plastic bag over her head and ligature around her neck. CPR attempts were unsuccessful, and she was pronounced dead shortly after. She died just days before she was due to be transferred to a new placement to receive specialist treatment for her condition.
Laura’s mother, Joanna Davis, said:
I am devastated by the death of my daughter. I feel she was badly let down by the services commissioned to protect her life and that her death was entirely preventable. I am grateful to the jury for recognising the serious failures and deficiencies by both hospitals responsible for her care which caused her death.
This inquest has been a long and difficult process for our family. Despite the serious failures in evidence by hospital staff, we as a family were subjected to the most aggressive questioning of the inquest by the hospitals’ lawyers in an attempt to undermine our credibility. No grieving family should have to go through what we went through. I am pleased that despite this, the jury recognised the many failures which led to Laura’s death.
Joseph Morgan, solicitor at Bindmans LLP representing Laura’s family, said:
The jury’s strongly critical narrative conclusion exposes the numerous serious failures which caused Laura’s death by Arbury Court hospital, a privately run hospital using public funds that failed in its duty to ensure Laura’s safety. It also acknowledges the role Laura’s local hospital, Wotton Lawn, played in her death. It vindicates the concerns of the family who fought so hard for answers and accountability from both hospitals in the many years since Laura’s tragic death.
This case highlights numerous systemic failings within inpatient mental health services, including the failures of privately run hospitals to ensure patient safety, the scarcity of specialist treatment placements for patients with personality disorders and failures in information sharing between institutions. These failures are longstanding and endemic, in a system which is underfunded and unfit to ensure patient safety.
Joanna Davis is represented by solicitor Joseph Morgan of Bindmans LLP and barrister Christian Weaver from Garden Court North. They are supported by INQUEST senior caseworker Selen Cavcav.