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Manchester Evening News
Manchester Evening News
Martyn Halle, John Siddle & Mary Stone

'Serious failures' led to death of young woman, 22, in mental health clinic 120 miles from home

A mum says her daughter who died at a mental health clinic 120 miles from home was 'badly let down' by the staff who were meant to protect her. Laura Davis, 22, took her own life after being given a plastic bag and allowed access to a ligature at a psychiatric intensive care facility in Warrington.

An inquest has criticised Arbury Court clinic for the 'unsafe practice' of giving patients high-risk items, GloucestershireLive reports. The jury found that the staff made 'serious failures' by not taking the ligature off Laura or upping observations.

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After the hearing, Laura’s mum Joanna, a former mental health worker, said: “It’s hard to believe that they allowed someone who was clearly suicidal to keep items that were dangerous. She was displaying all the behaviours on that day that showed she needed to be watched and protected.” Laura's mum Joanne has spoken of her heartbreak after a string of failings came to light.

Laura was moved to Arbury Court in November 2016 from Wotton Lawn, an NHS mental health unit near her home in Cheltenham, Glos, the inquest heard. Arbury Court is one of 43 hospitals and clinics run by Elysium Healthcare, whose parent firm has raked in more than £700million from the NHS and local clinical commissioning groups in two years – and one director was paid £690,000.

Laura had self-harmed extensively, and there was a suspected suicide attempt in October 2016. But the hearing in Warrington was told Wotton Lawn failed to warn Arbury Court when it transferred her or mention the materials she had used.

Her concerned parents met with Arbury Court clinicians to ensure they had all her records from Wotton Lawn and emailed a document outlining her risks. But Laura’s notes were not updated, and the jury heard staff remained unaware of her history,

On February 20, 2017, Laura was seen crying, and staff noted she had access to a ligature. It was not removed, and when she asked for a plastic bag, she was given one, the inquest heard.

"An hour later, she was found unresponsive in her bedroom. In its narrative verdict, the inquest criticised both Arbury Court and Wotton Lawn, saying the information transfer was “deficient”, communication between all the parties was “inconsistent”, and “record-keeping at Arbury Court was inadequate”.

Mum Joanna said after the findings: “Arbury Court should have been a place of safety for Laura, and it wasn’t. I am devastated by the death of my daughter. I feel she was badly let down by the services commissioned to protect her life and that her death was entirely preventable.”

Since her death, three other patients have died in Elysium facilities, more than a third of which are rated as either “inadequate” or, like Arbury Court, “require improvement” by the Care Quality Commission. After the inquest, Elysium said: “In the years following Laura’s death, important lessons have been learned and implemented across all of our hospital sites and the wider healthcare system to ensure better communication between providers.”

Gloucestershire Health and Care NHS Foundation Trust, which runs Wotton Lawn, said: “We have both carried out our investigation and participated in other processes to establish what more we could have done to prevent this tragedy from taking place.”

But campaigners fear more deaths, with charity Inquest saying high-risk items like those Laura used are still available in mental health units.

Joanna added: “These private companies and the NHS talk about learning, and there isn’t. The same mistakes are repeated.”

Read more of today's top stories here.

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