Healthcare trust apologises after 'beautiful daughter' took her life at Sutton hospital

Nottingham Coroner’s Court concluded that opportunities were missed by Millbrook Hospital, after 31-year-old patient Amelia Rose was found to have self-ligatured at the bottom of her bed.

Amelia Rose had been struggling with poor mental health for a few years when she was admitted to Priory Kneesworth House on December 7, 2019.

While there, she self-harmed on at least two occasions, resulting in her being detained under section three of the Mental Health Act and transferred to Millbrook Hospital in Sutton-in-Ashfield on January 28.

Following arrival at Millbrook, a care plan was drawn up containing vital information about Amelia’s care, including regular, ten-minute observations.

It is claimed that, at 1.50pm on January 31, a healthcare assistant documented that Amelia was in her bed space and that the 10-minute observation had been completed. But it was later suggested that CCTV failed to show any observation being carried out from 12.59pm, when Amelia returned to her room from the communal area, to 1.53pm.

When a staff member did attend Amelia’s room, she was found to have self-ligatured at the bottom of her bed and was taken to King’s Mill Hospital where she passed away the following day on February 1.

The five-day inquest concluded on Monday, July 18, at Nottingham Coroners' Court. The jury found that Amelia most likely died by her own hands, but they were unable to determine her intent.

They outlined 'missed opportunities' to deal with Amelia’s distress at the time leading up to her death and Laurinda Bower, assistant coroner for Nottinghamshire, ruled that Amelia did not receive the care she should have from staff at Millbrook.

“Amelia’s care plan stated that if she exhibited certain early warning signs she was often able to approach staff,” said Lucy Wilton, inquest specialist and solicitor at law firm Nelsons, who aided Amelia’s family during the case.

“But if Amelia was unable to do this due to high levels of distress, staff were to provide one to one support at the time. The fact that this was not actioned on January 31 when she told staff she was struggling and requested medication is another example of Amelia being let down.”

Apology

The healthcare trust behind the hospital has apologised and said staff will address the findings raised in the inquest.

Dr John Brewin, chief executive of Nottinghamshire Healthcare NHS Foundation Trust, added: “We offer our sincerest condolences to the family and friends of Amelia Rose at this difficult time.

“The quality of care we offer to patients is really important to us, and we commissioned an external investigation and have already implemented many of the recommendations from this to ensure improvements are made and maintained.

“Following the outcome of the inquest we will address the coroner’s comments and findings to ensure the significant learning points are shared throughout the Trust.”

Graham and Yvonne Dooley, parents of Amelia Rose, said: “We take a little comfort from the conclusion and feel like some of our concerns have finally been listened to.

“Millbrook Hospital has provided some evidence to suggest that it is making the changes needed to ensure that what happened to Amelia doesn’t happen again. However, we feel that the multiple opportunities to help Amelia that were missed will stay with us forever.

“There were a few personal experiences that led to the deterioration of Amelia’s mental health and her admission to several hospitals all over the country.

“However, every time she was discharged, she was left with very little support, which meant that the circle would continue and she would inevitably end up back in hospital again.

“Despite everything she faced, our beautiful daughter was one of the kindest, most loving and caring people you could ever meet and the fact that hundreds of people attended her funeral is a testament to that. Amelia was admired, respected, loved and an inspiration to everyone that knew her.

“Amelia really wanted to get better, but she didn’t know how to cope. All she wanted was a fair chance at life but she was utterly let down by the people who were supposed to be keeping her safe.

“We know we can’t bring her back, but we don’t want Amelia’s death to be something that nobody learns from, or for other people to be unable to get the help they so desperately need. We have to be her voice now.”