A jury has concluded there were missed opportunities by mental health staff to prevent Marion Michel’s death.
A woman living with schizophrenia died after she stabbed herself with a knife that was given to her by mental health ward staff, an inquest heard. The inquest into the death of Marion Michel has found there were “poor access controls” for knives in Brockfield House in Runwell after Marion was given a knife despite a known history of self-harm.
Marion, 56, from Jersey, was diagnosed with schizophrenia in 1998 and had a history of intense periods of mental illness when she would hurt herself and, on two occasions, her partner. Marion was transferred to Brockfield House in 2018, after having been convicted of assault that year.
On March 4, 2022, Marion requested a large knife from a nurse on the Aurora Ward at Brockfield House in order to prepare lunch, which was given to her from a locked cupboard. At around 12pm, Marion was found unresponsive in the locked toilet of her flat, having sustained multiple stab wounds to her neck and torso.
The emergency alarm was raised and Marion was treated at the scene by staff and later paramedics, but tragically she could not be saved and died from her injuries at around 1pm. Following nearly two weeks’ worth of evidence, a jury reached their conclusions into Marion’s death on Friday.
The jury found that Marion took her own life but was “unable to determine her intention at the time she did”. The jury found there to be an absence of a focussed risk assessment with respect of Marion having unsupervised access to knives before being transferred to the Aurora Ward in September 2021, in the context of previous self-harm and violence involving knives. The jury said this “possibly contributed significantly” to Marion’s death.
The jury also said that “inadequate processes and poor controls around access to knives increased the possibility of this”. The jury continued: “Given what was known by clinicians and staff on Aurora Ward with regard to Marion’s capacity, historically, to suffer sudden and extreme deterioration in her mental state leading her to inflict extreme violence against herself or others, was sufficient or insufficient consideration given to the known potential triggers for such deterioration (such as fear of abandonment and sudden change to plans or routines).
“We concluded that insufficient consideration was given to the known triggers for deterioration. We conclude that this possibly contributed significantly to Marion’s death.”
They added: “We concluded there was a missed opportunity for staff to consider the cumulative effect of changes on Marion’s mental health. In the absence of a clear clinical explanation for Marion’s death, we concluded that this possibly contributed significantly to her death.”
The inquest conclusion comes after The Essex Partnership University NHS Foundation Trust (EPUT), which runs Brockfield House, was rated “requires improvement” by the Care Quality Commission. Inspectors found existing issues were still present and some staff were sleeping when they were observing vulnerable patients.
Earlier this year, the government granted statutory powers to an inquiry into 2,000 deaths under the trust, as the previous non-statutory inquiry was not strong enough.
Credit Ellis Whitehouse
