10 December 2018

Before HM Assistant Coroner Lydia Brown
Leicester City and South Leicestershire Coroner’s Court
Opened 19 November, concluded 7 December 2018

Late on Friday (7 December) a jury inquest concluded that neglect by the Leicestershire Partnership Trust contributed to the death ‘by misadventure’ of Amanda Briley. Amanda was 20 years old when she was found unconscious with a ligature at The Bradgate Mental Health Unit whilst an inpatient detained under the Mental Health Act. She died in hospital two days later on 28 December 2016.

Amanda had a history of serious mental ill health and prolific self-harm. At 13 years old she came under the care of Warwickshire Child and Adolescent Mental Health Services (CAMHS) and at 15 she was diagnosed with Autism Spectrum Disorder (ASD). She was admitted as an inpatient on multiple occasions.

Amanda had been granted overnight leave with her family on Christmas Eve 2016. Detailed arrangements were agreed to support her home leave, including the need to resume constant observations immediately upon her return to the hospital. Yet following her return to the ward the plan was not followed and she was left on hourly observations. Amanda was found in her hospital room during the early hours of 26 December following a ligature incident.

The inquest jury found multiple failures in the response and decision making surrounding Amanda’s care, including:

• It was not appropriate for Amanda to remain on the Beaumont Ward, Bradgate Mental Health Unit for longer than crisis cover;
• Lack of autism awareness and training of staff in the Unit adversely affected her care;
• Systems in place for identifying, assessing and planning for Amanda’s risk of self-harm were not effectively utilised;
• Reflecting unsuitability of the Unit, safeguarding concerns should have been raised from the time of her final admission on 4 June 2016;
• A failure to adequately train staff on their safeguarding responsibilities;
• A failure by all parties concerning knowledge and operation of the “Winterbourne” register;
• Failures and delay around identifying and co-ordinating Amanda’s transfer to a suitable alternative unit;
• Leave planning for Amanda’s Christmas visit to her family was not appropriate and not in accordance with managing her risk and failed to involve consultation and input with those best positioned to develop a plan.

Ahead of the inquest Leicester Partnership Trust admitted the unacceptable failure to place Amanda on the correct level of observations following her period of 24 hour leave when she returned to the ward on 26 December 2016.

At the time of her death Amanda was awaiting availability of a bed at St Mary’s Hospital in Warrington, a specialist inpatient unit for people with autistic spectrum conditions. The inquest heard evidence that the unit only had four beds for women.  A placement did not become available until March 2018.

INQUEST is aware of numerous concerning deaths at the Bradgate Mental Health Unit, both recently and in previous years. In 2012, Leicester Partnership Trust was the subject of an independent investigation following eight self-inflicted deaths by inpatients of the Bradgate Unit during a three year period.  Further safeguarding investigations remain underway concerning Amanda’s death and the operation of the Unit. 

The coroner intends to issue a Prevention of Future Death report in due course.  

The family of Amanda Briley said: “All we hope is that lessons have been learned and that what happened to Amanda cannot be allowed to happen to anyone else, or any other family.  We thank our legal team and INQUEST for all their support.” 

Victoria McNally, caseworker at INQUEST said: “Evidence throughout Amanda’s inquest has pointed to the abject and systematic failures that lead to her death.

The jury’s findings are a shaming condemnation of this Trust’s systems and practises in the operation of basic safeguarding standards and in the dangers to which Amanda was exposed in being forced to remain in a unit so unsuited to someone with Autism. 

The mental health of young people is said to be a current political priority.  We call on the mental health Minister to address this family personally in explaining how the changes now underway across the mental health system will address the failures exposed and stop another death like Amanda’s.”

Megan Phillips of Bhatt Murphy solicitors, who represented the family, said: “It has been a bitter experience for Amanda’s family listening day after day to evidence exposing the wholescale failures of training and inadequate care on behalf of individual staff that contributed to Amanda’s death.  The jury’s findings are a damning indictment of those failings and the neglect that led to her death. 

It is now hoped that the appropriate bodies seek to ensure that the failings that contributed to Amanda’s death are rectified and not allowed to occur again.”

ENDS

NOTES TO EDITORS  

For further information, interview requests and to note your interest, please contact Lucy McKay and Sarah Uncles on 020 7263 1111 [email protected] [email protected]

INQUEST has been working with the family of Amanda Briley since January 2017. The family is represented by INQUEST Lawyers Group members Megan Phillips of Bhatt Murphy Solicitors and Maya Sikand of Garden Court Chambers.

The Interested Persons represented in the inquest proceedings are:

• Family represented by Bhatt Murphy Solicitors
• Leicestershire Partnership Trust (LPT) represented by Browne Jacobson Solicitors
• University Hospitals of Leicester (UHL) represented by Browne Jacobson Solicitors
• Leicester County Council (LCC) represented by Adult Social Care for Director of Law and Governance
• Clinical Commissioning Group (CCG) represented by Mills and Reeve
• East Midlands Ambulance service (EMAS) represented by Weightmans solicitors.
• Care Quality Commission (CQC)

The 2012 investigation into Leicester Partnership Trust following eight self-inflicted deaths by inpatients of the Bradgate Unit during a 3 year period, 2010-2012 can be read here.

Since this 2012 report, INQUEST is aware of multiple further deaths at the Bradgate Unit in which the Trust has been highly criticised.  There is no way of identifying how many deaths have occurred or the issues arising in those cases, since accurate publicly available data relating to the number of in-patient deaths for mental health institutions remains unavailable.  The failure to operate a clear system of publication sits at odds with all other state detention settings. 

INQUEST has consistently called for the publication of all key data relating to the deaths of mental health in-patients, necessary to ensure public oversight and visibility relating to deaths in mental health institutions.