Mother’s death at NHS mental health unit was third in 15 months, sparking calls for reform

‘Emma felt like she was being thrown out to the street,’ says her mother Debbie Taylor after inquest jury said discharge procedures may have contributed to death

Mental Health Act allows patients to be detained when they are a risk to themselves or others (Alamy)

The death of a young mother at an NHS mental health unit where three patients died in a 15 month period has ignited calls for a national watchdog to ensure lessons are learned and future deaths prevented.

Mother of five Emma Butler, 33, died in March 2017 from fatal injuries sustained after self-harming on a period of unsupervised leave from the Whiteleaf Centre, run by Oxford Health NHS Foundation Trust.

Emma had been admitted to the unit in May 2016 after being sectioned under the Mental Health Act, which includes detention powers for patients who pose a risk to themselves or others.

But Emma’s parents say the trust had been discussing discharging Emma despite recent episodes of self-harm, and no real improvement in her condition.

“She felt like she was being thrown out to the street,” Emma’s mother Debbie Taylor told The Independent. “She wanted to leave there when they had made her better and not because they couldn’t deal with her.”

“It was far too rushed trying to discharge her, and certainly too early to be letting her out on unescorted leave.”

An inquest into Emma’s death at Beaconsfield Coroners Court, Buckinghamshire, concluded this week.

At the inquest, Oxford Health said the prospect of discharge was used to make Emma engage with treatment and she would not have been discharged while still unwell, the family’s solicitor’s Leigh Day said.

“But they never gave Emma that information,” Ms Taylor said. “As far as Emma was concerned, she was being discharged no matter what she did.”

Emma had a history of self-harm and was diagnosed with depression at the age of 15, but she was only sectioned under the Mental Health Act for the first time in March 2016 and spent much of the next year at Whiteleaf.

Senior coroner Crispin Butler concluded at the inquest that there was no evidence she intended to take her own life.

Emma also made a call to the unit’s support line 15 minutes before she was found with fatal injuries, but the inquest raised concerns this was never recorded in Emma’s notes and no staff recall receiving it.

“Emma understood the number she had was so she could call the ward if she needed support,” said Sophie Wells, a solicitor at Leigh Day.

“If a patient hits a point of crisis and actually there is no one there, that can obviously lead to really serious incidents.”

The inquest jury found that multiple failings had occurred and concluded it was possible Emma’s care and discharge planning “contributed in more than a minimal or trivial way to her death”.

As did a recent change in the way it decided on her unsupported leave from the unit.

There were similar findings raised during an inquest – earlier this year – into the death of 19-year-old Zoe Watts, another patient of the unit who died just days before Emma.

Both women died 15 months after a patient on Whiteleaf’s male ward, Jack Portland, 29, died from an unintentional overdose during another period of unescorted leave. An inquest again found failings.

Jack and Zoe’s deaths each triggered a Prevention of Future Deaths report from the coroner, and a similar report is being considered by the coroner in the wake of Emma’s inquest.

However her family and the solicitors who led the inquest say these systems are not adequate for ensuring lessons are learned.

“I think there should be another body (to make improvements) absolutely,” Ms Taylor said. “Three deaths is unacceptable.”

“We just feel it could have been prevented. They’re supposed to be making changes from the two deaths before – one was quite a bit before that.

“They obviously haven’t made the right changes or got their act together to save our girl, and the young girl (Zoe).”

There were also repeated issues around Whiteleaf’s communication with family members, highlighted in all three inquests – and recognised as an issue nationally in a major independent review of the Mental Health Act published last week.

In Emma’s case her parents woke up to a voicemail, made five hours after she had been discovered with injuries that would turn out to be fatal, where staff said she had self-harmed but it was “not urgent”.

The extent of her injuries were only made clear when a nurse from Stoke Mandeville Hospital said they should urgently attend the hospital.

“We rushed down there, and when we walked through ICU, the nurse who phoned me said: ‘She’s in a bad way, she’s critically ill. I’ll take you to her’,” Ms Taylor said.

“She was on kidney machines, life-support, sedated, tubes out of her neck. I just looked and said ‘what wasn’t urgent about this?’.”

“She’d been conscious until three o’clock in the morning, but we never got the chance to know she knew we were there, or to speak to her, or to comfort her. That to me is just unacceptable.”

Because this wasn’t material in Emma’s death it could not be considered by the coroner.

“We must question the systems of learning that have allowed three deaths at the same unit within a 15 month period, exposing such similar, basic patterns of failure,” said Victoria McNally, a caseworker at the Inquest legal group, which Leigh Day is part of.

“Inquest has consistently called for a national body responsible for overseeing learning to prevent unnecessary deaths from failed learning.”

A spokesperson for Oxford Health NHS Foundation Trust said it had taken note of the jury findings, and had commissioned its own review of the circumstances around Emma’s death.

“We would again like to offer our condolences to Emma’s family and friends,” the spokesperson said.

“All the recommendations from this review have been accepted, actions on most are complete and others are underway or ongoing.

“Should the coroner identify any other areas of concern, we will seek to address those as a matter of urgency.”