Women died after ‘gross failings’ by scandal hit mental health trust

How many more must die before there is a real change in Essex mental health services? asks leading charity

A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths.

Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals.

The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”.

Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust.

The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward run by the hospital.

There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.”

It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. 

Bethany’s family, represented by Fosters’ Solicitors said: “We are grateful that we now have the answers we have been longingly seeking for after three long years. We feel vindicated by these answers and that Bethany’s death was taken seriously by the jury. We are finally able to remember Beth for the lovely, funny beautiful daughter, sister and aunty she was instead of focusing only on how she died. We thank Jonathan and Jenny for their fantastic support in reaching this stage. We now have justice for Beth!”

Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families.

Essex Partnership University Hospital Foundation Trust, which runs the services, is facing an independent inquiry which is likely to be the biggest ever seen across a mental health service.

However, families are campaigning for the independent inquiry to be converted into a statutory public inquiry which would be able to compel those involved to give evidence.

The trust has previously had a police investigation into 24 deaths, which did not end is prosecution and was prosecuted by the Health and Safety Executive for failing to manage known ligature risks ahead of the deaths of 11 patients in June 2021. 

Ms Lilley’s death follows that of Matthew Leahy in 2012, whose death along with another young man’s was investigated by the Parliamentary Health Service Ombudsman which and heavily criticised the hospitals.

Ms Lilley, described as an “ambitious young woman”, was a healthcare assistant and worked in a local GP surgery. She had a history of complex mental health difficulties, and self harm, and prior to her death had several admissions to inpatient units.

According to INQUEST after a period of wellness she suffered a deterioration in her mental health following the death of her father which “led to a rapid escalation of self-harming and suicidal behaviours.”

On 15 January 2019 after an attempt at self harm, she was taken to A&E in Colchester where she was placed on “continuous eyesight observations”. A decision was later taken to transfer her to Thorpe ward within the Basildon mental health unit.

Jurors at her inquest said the trust had failed to carry out a risk assessment, that there had been an inappropriate handover between the two hospitals and a lack of collaboration.

According to the findings, staff at Thorpe Ward were “unaware” that she was going to be transferred, had no clinical history for her and were unaware she was on continuous eyesight observations, also called level three observations. 

On the 16 January staff downgraded her observation level to level one, which means she would be checked every 30 to 60 minutes. She was later found hunched over by staff and 18 minutes later ambulance was called and she was tragically pronounced dead.

“Given her risk factors and recent self-harming incidents, Beth should not have been downgraded to level 1 observations,” a summary of the jury’s conclusions found.

The trust admitted reducing her observation level without a full risk assessment and although staff claimed to have carried out the last observation before she died the jury found this did not in fact happen.

Lucy McKay, spokesperson for INQUEST, said: “Sadly Bethany is one of many people who have been failed and neglected by Essex University Partnership Trust and other Essex mental health services in recent years.

“The conduct of Essex mental health services has been subject to significant public scrutiny, including extensive campaigning by bereaved families and now an ongoing independent inquiry.

This evidence of this inquest, both on the actions of Essex University Partnership Trust before and after Bethany’s death, are a reminder of just how urgent and necessary such scrutiny is. How many more must die before there is a real change in the culture and leadership in Essex mental health services?”

Credit Rebecca Thomas The Independent

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