Late on Wednesday, 1 June 2016, after hearing 11 days of evidence, an Inquest jury at West Sussex Coroner’s Court returned a unanimous conclusion that neglect (a gross failure to provide basic care and attention) contributed to the death of 14 year old Amy El-Keria who hung herself whilst admitted as an informal mental health patient at Ticehurst House hospital, a private hospital run by the Priory Group.
In its narrative conclusions, the jury identified wide ranging individual and systemic failures on the part of the hospital, including:
- inadequate staffing levels and a consequent inability to provide care specified in Amy’s care plans;
- inadequate risk assessments and care planning;
- inadequate ligature management, including placing Amy in an unsuitable room and allowing her access to the scarf with which she hung herself;
- inadequate systems for identifying and managing ligature risk;
- failures to share key information relevant to Amy’s risk of suicide and inadequate information sharing systems;
- failures to adequately address bullying;
- failures in relation to observations; and
- failures in the emergency response (including delays in calling an ambulance, contacting the duty doctor and commencing CPR) and an inadequate emergency response system.
The family were represented by Raj Desai instructed by Tony Murphy of Bhatt Murphy solicitors.
Further details can be found on the INQUEST website here.