The tragic "self-inflicted" death of a "badly let down" young woman at an impatient mental health facility was "facilitated" by staff, a report has ruled.
Laura Davis was discovered unresponsive on her bed at Arbury Court in Warrington and was found to have died by asphyxia.
"Catastrophic decisions" were made in the 22-year-old's care, who had a diagnosis of emotionally unstable personality disorder, her family's lawyers said.
The 22-year-old had been staying in the Warrington centre for three months following her struggles with mental health, having been a victim of three previous sexual assaults which had triggered a history of serious self-harm.
The Devon-born woman, who had ambitions to be an RAF officer, was transferred to the privately run mental health unit, Arbury Court.
It was run by Elysium Healthcare, but Laura's placement was funded by the NHS.
There were delays finding her a different home, and her death happened just days before she was due to be transferred to a new specialist facility.
Before being moved to Warrington, Laura was admitted to Wotton Lawn mental health hospital in Gloucestershire in June 2016.
Today, a report from Warrington Safeguarding Adults Board has concluded staff "facilitated Ms Davis' means of self-harm on the day of her death."
The investigation also highlighted other failings including:
- the expectation of rigorous attention to Laura’s safe care was not met by Arbury Court
- staff facilitated Laura’s means of self-harm on the day of her death by granting her unsupervised use of problematic materials, despite what was known to staff about her recent self-harming behaviour and well-being
- widespread issues in the recording of information about Laura’s risks to herself and sharing this information between the agencies involved in Laura’s care and with her family
- efforts to transfer Laura to a more suitable placement were hampered by the scarcity of suitable placement options and failures in information sharing between the agencies involved
- missed opportunities for independent scrutiny of Laura’s care through safeguarding.
The report has made eight recommendations directed at the various agencies involved, including NHS England.
Joanna Davis, Laura’s mother, said: “I am devastated by Laura’s death.
"I believe that she was badly let down, both by Wotton Lawn who sent her so far away from home and by Arbury Court where she eventually died.
"After such a long wait for answers, I am pleased that the Safeguarding Adult Board’s investigation has highlighted some of the serious failures in her care.
"I am now looking towards the inquest into Laura’s death where I hope to finally obtain answers from those responsible for her care as to how her tragic death was allowed to happen.”
Joseph Morgan, of Bindmans LLP, who represent Joanna Davis, said: “The findings of the Safeguarding Adults Review reveal numerous failures in Laura’s care, both in terms of the catastrophic decisions that led to her death and the wider management of her care by all agencies involved.
"Her case highlights the widespread issues across mental health services regarding failures in risk assessments, failures in record keeping and information sharing, and the inadequate provision of suitable placements.”
Laura was from Brixham in Devon, and grew up in Cheltenham.
She enjoyed flying drones, and was a hard-working and high achieving student, her family said.
She had ambitions of going to Wellbeck college and then on to Sandhurst to become an RAF officer.
Her family described her as very caring and intuitive, and "she always put others before herself."
Selen Cavcav, a senior caseworker at Inquest, a charity providing expertise on state related deaths and their investigation, said: "Behind so many deaths of young women in mental health care there is a history of sexual abuse and complex mental health needs.
"So many people in need end up waiting for months if not years for a suitable placement.
"Long waiting lists and lack of suitable services is simply costing lives.
"Three years on from Laura's death, this review is making some bold criticisms and strong recommendations which we hope will be implemented without any further delay.”
A spokeswoman for Elysium Healthcare said: "We are regretfully not in a position to comment on this tragic case until the conclusion of the formal inquest, at which point we will make a full statement."
The ECHO has approached Warrington Council for further comment.
