Background Emily was born on 11 February 1995. At the age of 12, she began to be sexually abused by her step-father and this continued until she was 15 years old. Emily finally reported the abuse and her stepfather was arrested and subsequently convicted after trial.

Emily began self-harming and making attempts on her own life at around the time the abuse began. Emily attempted to hang herself as early as 2012. She was diagnosed with PTSD in 2013 after finally being diagnosed with Emotionally Unstable Personality Disorder (EUPD) in 2018. EUPD is sadly a common condition in women who have been sexually abused at a young age. She experienced flashbacks of the abuse and was hearing her abusers voice which was derogatory towards her and told her to harm herself.

Emily was admitted to Holt Ward at Newtown Hospital as an informal patient on 19 March 2020. The same evening, she had a crisis where she began initially scratching herself and then smashed a tissue holder in the female toilets and began to cut herself. She had been agitated on the ward and attempts to de-escalate were unsuccessful. She was restrained by four members of staff and remained restrained for around 20 minutes. She refused oral medication. The core trainee Doctor called the Consultant who agreed for a rapid tranquiliser injection to be administered in Emily’s best interest. He advised ward staff to give her this injection only as a last resort. She remained under informal admission.

On 20 March 2020, a Ward Review was undertaken where the doctor noted that the impression he got of Emily was “EUPD in crisis”. The doctor wrote in Emily’s care plan that “if she turns blue/unconscious that would be an indication of losing capacity and we can intervene in her best interests…. If she continues to display aggressive behaviour and poses a risk to others whether staff or patient it should be dealt with under the Criminal Justice System and police called…” Later that day, she was found to have tied a ligature around her neck using a sock. Ligature cutters were required to remove the item and Emily tried to hit out at staff resulting in staff using restraint intervention until it was safe to disengage.

On 21 March 2020, Emily was found to be banging her head on her bedroom wall and presenting as distressed. She declined all her normal medication. It is reported that at 14:00 she pressed the nurse call button in her bedroom and was found with a t-shirt tied around her neck and her face was purple/blue but she was apparently breathing. Later that day, at around 20:15 Emily approached the nursing office and knocked on the door. As staff opened the door she pushed her way through and took a pen from a member of staff and a swipe card from another member of staff. Staff used restraint on Emily and held her to the floor for a period of 20 minutes. Emily continued to struggle and kick out and presented as very agitated. The decision was made to place Emily under s.5(4) of the Mental Health Act due to the risk to herself and others. The doctor advised staff to give Emily an intramuscular tranquiliser (IM) to calm her and relieve her agitation, however a member of staff restraining Emily told others that they could not give her a rapid tranquilisation injection as she was an informal patient and had already had an IM tranquiliser administered under best interest/Mental Capacity Act on 19 March 2020.

Once Emily had been released from restraint she returned to her room, where several further incidents took place in quick success: smashing a cup/mug, smashing a mirror, banging her head on the radiator and kicking out at staff. During this time, staff remained outside her room constantly, although did not formally increase her observations from every 15 minutes. They decided to leave the area.

Four minutes later, on a random observation check, Emily was found to have tied a ligature around her neck. She refused to remove the ligature and staff had to cut it. She had used the strap of her bra top that she was wearing. At this point, Emily was wearing a cropped bra top, a hoody, jeans and underwear and staff felt it was undignified to ask her to remove further items of clothing. The bra top she had ligatured with was not removed. Staff returned 7 minutes later to find her face down on her mattress, having removed the bra top and creating a thick and tight ligature.

Emily was taken to hospital where she fell into a coma and sadly passed away on 23 March 2020. Conclusions:

The inquest jury concluded via questionnaire that:

• At any point on the evening of 21 March 2020 Emily lacked capacity to make a decision about accept rapid tranquilisation medication. • Staff did not carry out an adequate assessment of Emily’s capacity at that point. • The failure to adequately assess Emily’s capacity to make that decision probably caused or contributed to her death on 23 March 2020. • On the evening of 21 March 2020 staff on Holt Ward should have administered IM Lorazepam to Emily under “best interests”. • The failure to administer IM Lorazepam that evening probably caused or contributed to Emily’s death 23 March 2020. • Following the first ligature incident on the evening of 21 March 2020, staff on Holt Ward should have removed the bra top which Emily had used to make that ligature. • The jury were unable to say whether removal of the bra top would probably have caused or contributed to Emily’s death on 23 March 2020 • Emily’s death was contributed to by neglect.

Tessa Hutchinson, of GT Stewart Solicitors representing Emily’s father and sister said: “The evidence in this case clearly highlighted serious failings by staff on Holt Ward to provide Emily with basic medical care and attention. The fact that staff left Emily alone for 7 minutes (knowing she had tied the previous ligature in 4 minutes), that they didn’t give her an IM rapid tranquiliser to relieve her distress nor did they remove the crop top she had ligatured with minutes before unfortunately all contributed to Emily’s death. It is the family’s view that had they just taken one of the above measures, Emily would still be with them today. The finding of neglect has vindicated what the family knew all along: the State has failed Emily and their family. I sincerely hope that Worcestershire Health and Care Trust take these failings on board and give serious consideration to the Regulation 28 report”

Fatima Jichi, Garden Court Chambers, counsel for Emily’s father and sister said:

“It is disappointing to see three inquests conclude this week where young women with EUPD have been similarly failed whilst under the care of the state. It’s very concerning that Emily was held in restraints multiple times and forced to take medication whilst being an informal/voluntary patient. The use of de facto detention on patients with EUPD gives the state a remarkable level of power without any accountability or challenge and is “oppressive” (as described by Emily’s family during the inquest). It is also concerning that Emily’s care plan included the criminalisation of her distress and the symptoms of her mental illness, by suggesting this is dealt with through the police and criminal justice system. We need to explore solutions that move away from detention, either in hospital or in prison, as the solution to medical issues”

Emily’s family are represented by INQUEST Lawyers Group members Tessa Hutchinson of GT Stewart Solicitors and Fatima Jichi of Garden Court Chambers. With thanks to Tom Stoate of Doughty Street Chambers for his initial advice and representation.