Woman died after ‘gross failings’ by scandal-hit mental health trust

How many more must die before there is a real change in Essex mental health services? asks leading charity

Bethany Lilley (INQUEST)

A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths.

Bethany Lilley, 28, died on 16 January while she was an inpatient at Basildon mental health unit, run by Essex Partnership University NHS Foundation Trust.

The inquest this week examined the circumstances of her death, and concluded that it was contributed to by neglect due to a “plethora of failings by Essex University Partnership Trust”.

Following the three-week inquest, heard before coroner Sean Horstead, a jury found that “neglect” had contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust.

The jury identified a number of failings in her care, including evidence that cocaine had made its way onto a ward run by the hospital.

There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units”.

It was also concluded that staff had failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations.

Bethany’s family, represented by Fosters Solicitors, said: “We are grateful that we now have the answers we have been longingly seeking for after three long years. We feel vindicated by these answers and that Bethany’s death was taken seriously by the jury. We are finally able to remember Beth for the lovely, funny, beautiful daughter, sister and aunty she was, instead of focusing only on how she died. We thank Jonathan and Jenny for their fantastic support in reaching this stage. We now have justice for Beth!”

Ms Lilley is one of several patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families.

Essex Partnership University NHS Foundation Trust, which runs the services, is facing an independent inquiry which is likely to be the biggest ever seen across a mental health service.

However, families are campaigning for the independent inquiry to be converted into a statutory public inquiry, which would be able to compel those involved to give evidence.

The trust has previously been subject to a police investigation into 24 deaths, which did not end in prosecution, and was fined by the Health and Safety Executive in June 2021 for failing to manage known ligature risks ahead of the deaths of 11 patients.

Ms Lilley’s death follows that of Matthew Leahy in 2012, whose death, along with that of another young man, was investigated by the Parliamentary and Health Service Ombudsman, which heavily criticised the hospitals.

Ms Lilley, described as an “ambitious young woman”, was a healthcare assistant and worked in a local GP surgery. She had a history of complex mental health difficulties and of self-harm, and prior to her death had been admitted several times to inpatient units.

According to Inquest, a charity providing expertise on state-related deaths, after a period of wellness she suffered a deterioration in her mental health following the death of her father, which “led to a rapid escalation of self-harming and suicidal behaviours”.

On 15 January 2019, after an attempt at self-harm, she was taken to A&E in Colchester where she was placed on “continuous eyesight observations”. A decision was later taken to transfer her to Thorpe ward within the Basildon mental health unit.

Jurors at her inquest said the trust had failed to carry out a risk assessment, and that there had been an inappropriate handover between the two hospitals and a lack of collaboration.

According to the findings, staff at Thorpe ward were “unaware” that Ms Lilley was going to be transferred, had no clinical history for her, and were unaware she was on continuous eyesight observations, also called level 3 observations.

On 16 January, staff downgraded her observation level to level 1, which means she would be checked every 30 to 60 minutes. She was later found hunched over by staff, and 18 minutes later an ambulance was called and she was pronounced dead.

“Given her risk factors and recent self-harming incidents, Beth should not have been downgraded to level 1 observations,” a summary of the jury’s conclusions found.

The trust admitted reducing her observation level without a full risk assessment, and although staff claimed to have carried out the last observation before she died, the jury found this did not in fact happen.

Lucy McKay, spokesperson for Inquest, said: “Sadly Bethany is one of many people who have been failed and neglected by Essex University Partnership Trust and other Essex mental health services in recent years.

“The conduct of Essex mental health services has been subject to significant public scrutiny, including extensive campaigning by bereaved families and now an ongoing independent inquiry.

“This evidence of this inquest, on the actions of Essex University Partnership Trust both before and after Bethany’s death, are a reminder of just how urgent and necessary such scrutiny is. How many more must die before there is a real change in the culture and leadership in Essex mental health services?”

The families campaigning for a public inquiry have launched a petition, and are currently appealing a judicial review decision.

Paul Scott, CEO of Essex Partnership University NHS Foundation Trust, said: “Our thoughts are with the family and friends of Bethany Lilley at this difficult time. Since the tragic incident in 2019 we have put in place a number of actions, improving communications, the process for observations and strengthening collaboration between services across the trust.”