Inquest ‘Gross failures’ in Lily’s care at mental health hospital
AN inquest jury found there were “gross failures” in a woman’s care at a private mental health hospital after she drank too much water.
Lily Lucas, aged 28, had been admitted to Milton Ward at the Cygnet Hospital at Kewstoke, Weston-super-Mare under Section 3 of the Mental Health Act 1983, after an escalation in her mental health symptoms on June 15, 2022.
She initially made good progress, but her mental health again deteriorated around August 2022. She later died after being found unresponsive whilst an NHS inpatient at Cygnet Hospital in September 2022.
An inquest at Avon Coroner’s Court has found widespread failings in the care provided to Lily and concluded that her death was contributed to by neglect. Lily’s family described her as beautiful, loving, generous and hilarious.
Lily had a history of mental ill health and a diagnosis of schizophrenia. She had hoped this hospital admission would be an opportunity to get better through engaging with therapeutic opportunities at the unit.
Lily was prescribed Clozapine to help manage her symptoms on September 5, 2022. She was scared about taking the drug, as she was aware of the severe side effects some people suffered. Her family raised her concerns with the treating team.
In the hours leading up to her collapse, Lily, from Malmesbury, was noted by numerous staff on the ward to be drinking excessive volumes of fluid and eating large quantities of food. She was also seen vomiting profusely and acting in a disinhibited and disorientated way.
This was uncharacteristic behaviour for Lily and ought to have been recognised as a concerning deterioration in both her physical and mental health. On the evening of September 8, 2022, Lily was found unresponsive in her room and after CPR was transferred to the Bristol Royal Infirmary for treatment. She subsequently died on September 9, 2022.
An inquest jury concluded that there were gross failings in her care amounting to neglect, namely Lily died from cardiac arrest due to complications of psychogenic polydipsia, resulting from her schizophrenia. They also found Lily’s worsening mental and physical condition was not adequately monitored and neither urgent nor adequate medical attention was provided nor sought, in line with Cygnet policies.
The jury found there was inadequate response and concern for Lily’s ongoing presentation and opportunities were missed to render care which would have prevented Lily’s death.
During the inquest, the jury heard evidence about how the ward had unsafe staff levels on shift for that day. Despite there needing to be a minimum of two registered nurses and six support workers on shift on the ward, there only was one registered nurse and five support workers, all of whom were agency or bank staff.
This was further compounded by the requirements of other patients on the ward. Four of the support workers were engaged with enhanced observations for other patients with high needs which meant there was only one support worker available to support the ward generally.
In her evidence, the nurse in charge explained she was unable to fulfil her role properly due to unsafe staffing levels. She conceded that this meant that opportunities to save Lily’s life were missed.
Speaking afterwards Lily’s family said: “We are grateful to the jury for their careful consideration of the inquest over the eight days. Their conclusion confirms our worst fears about the care that was provided to Lily during her time at Cygnet Hospital.
“Whilst we are glad that their conclusion recognises the significant and various failings in care provided to Lily it is nonetheless utterly heartbreaking to know that her death was entirely avoidable.
“We were alarmed by the lack of contrition from many of the Cygnet workers who gave evidence during the hearing, including some who failed to accept the clear inadequacies in their response to Lily’s condition even now, 18 months after Lily’s death. We miss her every day and always will.”