Mum's heartbreak over string of failures that led to daughter's death at just 22
A mum has slammed serious blunders that led to her daughter taking her own life at a private mental health facility run by a group paid millions by the NHS.
Laura Davis, 22, committed suicide after she was given a plastic bag and allowed access to a ligature at a psychiatric intensive care facility.
An inquest criticised Arbury Court in Warrington, Cheshire, for the “unsafe practice’” of giving patients high-risk items.
Staff made “serious failures” by not taking the ligature off Laura or upping observations, a jury found.
After the hearing, Laura’s mum Joanna, a former mental health worker, said: “It’s hard to believe that they allowed someone who was clearly suicidal to keep items that were dangerous.”
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She added: “She was displaying all the behaviours on that day that showed she needed to be watched and protected.”
Laura's mum Joanne has spoken of her heartbreak after a string of failings came to lightLaura was moved to Arbury Court in November 2016 from Wotton Lawn, an NHS mental health unit near her home in Cheltenham, Glos, the inquest heard.
Arbury Court is one of 43 hospitals and clinics run by Elysium Healthcare, whose parent firm has raked in more than £700million from the NHS and local clinical commissioning groups in two years – and one director was paid £690,000.
Laura had self-harmed extensively and there was a suspected suicide attempt in October 2016. But the hearing in Warrington was told Wotton Lawn failed to warn Arbury Court when it transferred her, or mention the materials she had used.
Her concerned parents met with Arbury Court clinicians to make sure they had all her records from Wotton Lawn and emailed a document outlining her risks. But Laura’s notes were not updated, and staff remained unaware of her history, the jury heard.
On February 20, 2017, Laura was seen crying, and staff noted she had access to a ligature. It was not removed and when she asked for a plastic bag, she was given one, the inquest heard.
The tragedy happened at Arbury Court in Warrington in 2017"An hour later she was found unresponsive in her bedroom. In its narrative verdict, the inquest criticised both Arbury Court and Wotton Lawn, saying the information transfer was “deficient”, communication between all the parties was “inconsistent” and “record-keeping at Arbury Court was inadequate”.
Mum Joanna said after the findings: “Arbury Court should have been a place of safety for Laura and it wasn’t. 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.”
Since her death, three other patients have died in Elysium facilities, more than a third of which are rated as either “inadequate” or, like Arbury Court, “require improvement” by the Care Quality Commission. After the inquest Elysium said: “In the years following Laura’s death important lessons have been learned and implemented across all of our hospital sites, and the wider healthcare system, to ensure better communication between providers.”
Gloucestershire Health and Care NHS Foundation Trust, which runs Wotton Lawn, said: “We have both carried out our own investigation and participated in other processes to establish what more we could have done to prevent this tragedy from taking place.”
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But campaigners fear more deaths, with charity Inquest saying high-risk items like those Laura used are still available in mental health units.
Joanna added: “These private companies and the NHS talk about learning and there isn’t. The same mistakes are repeated.”
The Samaritans is available 24/7 if you need to talk. You can contact them for free by calling 116 123, email [email protected] or head to the website to find your nearest branch. You matter.
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