A young woman died at an understaffed private west London mental health hospital due to “neglect” when staff failed to assess the risk she posed to herself, an inquest has found.
Bonnie Newton was just 20 years old when she took her own life in her room at the Cygnet Hospital in Ealing, west London in July 2019.
She was 100 miles away from her family in Wimborne, Dorset, and had been assured she needed to go to the private hospital for help with her mental health.
But West London coroners court heard of a catalogue of failings, including “unsafe” staffing levels and a lack of risk assessments vital to Bonnie’s safety.
Cygnet Health Care was hit with a £1.53 million fine in 2023 over Bonnie’s death, after it pleaded guilty in a Care Quality Commission prosecution for failing to provide safe care and treatment.
Bonnie’s family have now spoken publicly for the first time in the wake of the inquest, to call for better mental health care for vulnerable young people.
Bonnie’s mother Marie, speaking for herself, Bonnie’s father Jon, and her brother Alex, said: “Our hearts are broken. The pain both mentally and physically is like nothing else. Not only was Bonnie my daughter, she was my best friend. She was my world.
“Although Bonnie had her struggles, alongside her talent for singing and great sense of humour, she continued to be the most kind, polite, caring and wonderful daughter anyone could ever wish for. She will never be forgotten. What Bonnie had to go through shouldn’t happen to anyone. She didn’t want to feel the way she did, Bonnie was desperate to have a life without sadness.
“Bonnie was reluctant to transfer to Cygnet Ealing but was told she needed to so she could receive the dialectical behavioural therapy she had waited almost half her life for, and ultimately, for her to get better.
“However, she found it challenging and we found communication with the hospital was poor. Any responses we got seemed curt. All we were told was to ‘stop worrying and Bonnie was getting better’.
“I’ll always believe that if Cygnet, who were entrusted to care for Bonnie, had looked after her properly she would still be with us now.
“We just hope by sharing our story we can improve care for vulnerable young people. I wouldn’t wish the pain we face each day on anyone.”
Bonnie, who had been diagnosed with a personality disorder, spent 18 months as an inpatient at a hospital near her home, and was transferred to the New Dawn ward of Cygnet Hospital Ealing on 20 November 2018.
The inquest heard Bonnie became isolated and pre-occupied on 21 July 2019, and she was put on 15-minute observations the following day. Her mother also made a concerned call to the ward after speaking on a video call to Bonnie.
In the early hours of the following morning, Bonnie was found unresponsive in her room by the only mental health nurse on duty in the ward, and she died the following day.
At the time she was found, one of just two healthcare assistants on duty on the ward that night was on a break, and no effort had been made to bring in extra staff as cover.
The inquest was told that staffing levels on the night were “unsafe” as a minimum of two nurses and two assistants should have been on duty.
Lawyers from Irwin Mitchell, representing Bonnie’s family, said she had been involved in a serious incident involving a ligature four months earlier. However her care plans and risk assessments were not updated, and the safety of her room was not scrutinised properly.
When she was found unresponsive in her room, staff tried to use alarms which did not work, and they attempted “ineffective CPR” with Bonnie lying on her front, the inquest heard.
The jury concluded neglect had contributed to her death, and the “lack of documentation at Cygnet was insufficient to provide Bonnie with a safe level of care”.
Camilla Burton, an expert human rights lawyer at Irwin Mitchell, said Bonnie’s family believe her death was “entirely preventable”, and added: “Sadly, this isn’t an isolated incident. We continue to see too many cases of young people with mental health problems not receiving the level of care they deserve, often miles from home.
“Young people with mental health problems are some of society’s most vulnerable. We join Marie and Jon in calling for lessons to be learned from Bonnie’s death so other families don’t suffer a similar tragedy.”
A Cygnet spokesperson said: “We continue to extend our deepest condolences to Bonnie’s family and loved ones.
“We are always committed to enhancing our practices to ensure the delivery of safe, quality care. At the last inspection, the Care Quality Commission rated Cygnet Hospital Ealing as ‘Good’ and we continue to work closely with the CQC and other partners to uphold the highest standards of safety and provide compassionate care.
“Whilst this cannot change what has happened, we are not complacent and wish to take this opportunity to once again convey our sincere condolences to all those affected.”
