‘I thought she’d be safe’: A life lost by suicide in a place meant for recovery | Private medical care

“I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter Brooke Martin was admitted to Milton Keynes Mental Hospital.

Eight weeks later, Brooke committed suicide.

“I thought she would be well cared for, recover and be able to move on with her life. I can’t get over it,” Darbon said.

The inquest jury concluded that Brooke’s death could have been prevented and that private health care provider Elysium Healthcare, which ran the hospital, had failed to properly manage her suicide risk. He also found that serious failures in risk assessment, communication and setting compliance levels contributed to his death. Elysium accepted that if she had been placed under 24-hour observation, Brooke would not have died.

Brooke, who was autistic, wanted to become a veterinarian. Darbon remembers her as “very caring, considerate and sensitive”. But she was also troubled. She had a history of self-harm and suicide and first came into the care of NHS child and adolescent mental health services when she was 12.

In 2018, she was repeatedly sectioned under the Mental Health Act due to her self-harm and increasing suicide attempts. After a stay in an NHS facility in Surrey, she moved to Chadwick Lodge, which specializes in the treatment of personality disorders.

After a few weeks there, Brooke was doing well and the staff were pleased with her progress. She needed to move to Hope House, a separate unit of the hospital, to begin more specialized therapy for an emotionally unstable personality disorder, and was keen to make the switch.

But then the teenager’s mental health deteriorated again. On June 5, 2019, she attempted suicide. Five days later, she was seen twice in the evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later, she was found unconscious in her bedroom. She received CPR but died the following day at Milton Keynes University Hospital.

After hearing evidence of the care Brooke received in her final days, Tom Osborne, the inquest coroner, took the unusual step of issuing a notice preventing future deaths – a legal warning that details the changes that will must be brought to stop other people. die under the same circumstances. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as owner of Chadwick Lodge.

It set out the jury’s detailed criticisms of Elysium’s interaction with Brooke after her June 5 suicide attempt. They cited the hospital’s failures to release information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night of her death, and to place Brooke under observation. constant thereafter.

“[Handling potential ligatures] would and should have resulted in a full risk assessment and search of his room, which would have resulted in his observation level being increased to 1:1,” the jury concluded. “Brooke Martin, had she been constantly observed or had other safety measures in place, would not have been able to tie the ligature which caused her death and therefore would not have died on June 11, 2019 . »

Paul Martin, Brooke’s grandfather, said: ‘What happened was so fundamentally wrong, negligent, that it defies logic. How can a company that is supposed to take care of the vulnerable be so negligent? »

Brooke isn’t the only inpatient to die at an Elysium mental health facility. The charity Inquest represents six other families whose loved ones have died since 2016 while in its care.

The inquest into the death of 16-year-old Nadia Shah at an Elysium unit in Hertfordshire in 2019 revealed similar failures to Brooke’s case: delayed observation and access to ligatures – a dangerous combination. Nadia’s death was due to “a misadventure, to which the inadequate care at the clinic at Potters Bar contributed”, the jury heard.

Elysium Healthcare said it sent its deepest condolences to Brooke’s family and friends for “this tragic incident”. He reiterated what he said at the end of the inquest last July that after his death he immediately took ‘significant steps’ to improve patient safety at Chadwick Lodge.

He also committed to reflect on and “implement, as appropriate, … additional learning as a result of the survey … [to] ensure that our policies and procedures are as effective and responsive as possible in providing care to highly vulnerable people.

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