Inquest finds that unsafe staffing levels at Cygnet Hospital Ealing contributed to the death of a young woman.
The family of a young woman found fatally injured in an “unsafe” mental health hospital is campaigning to improve care for others.
In November 2018, a young woman was admitted to a ward in Cygnet Hospital Ealing. In July 2019, the young woman was able to take her own life while resident on the ward. Cygnet Ealing were aware of this young woman trying to harm herself in an almost identical way four months earlier, yet they failed to mitigate the known environmental risk to which she was exposed.
Cygnet Health Care was subsequently fined £1.53 million after pleading guilty in a criminal prosecution brought by the Care Quality Commission (CQC).
“People, especially those at such a frightening, vulnerable time in their life, should be able to expect safe care and treatment, so it’s unacceptable that this young woman’s safety wasn’t well managed by Cygnet Hospital Ealing when she needed them the most. This is why I welcome their guilty plea,” said Jane Ray, CQC deputy director of operations in London.
Cygnet acknowledged failings of providing a safe ward environment to reduce the risk of people being able to use a ligature; ensuring staff observed people intermittently in line with the company procedures; and not training staff to be able to resuscitate patients in an emergency.
Lack of oversight
Following the sentence on 21 September, 2023, the girl’s parents are now calling for improved mental health care among young people. It comes after an inquest jury concluded that the girl’s death was contributed to by neglect.
It concluded that “the lack of documentation at Cygnet” was insufficient to provide a safe level of care and that a lack of staff in management roles contributed to instability and caused a lack of oversight.
The inquest was told that one mental health nurse and two healthcare assistants were on duty on the night she died. When the patient was found, one healthcare assistant was on a break and the other was carrying out one-to-one observations on another patient. No attempt was made to bring additional staff from another ward to cover the break. The
inquest was told that staffing levels on the night were “unsafe” and that a minimum of two nurses and two assistants were required to cover a ward.
“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,” said human rights lawyer Camilla Burton at Irwin Mitchell, who is representing the family.
