She was rushed to Kingston Hospital but her life support machine was turned off three days later.
Over the course of her six months at The Priory, she had made at least 27 attempts at self-harm, yet her observation level was reduced just two days before her death.
This meant that rather than a healthcare assistant maintaining constant watch over her movements, she was assessed six times an hour during the daytime.
In a letter sent on 13 September, consultant psychologist and clinical lead Dr Adrian Lord wrote to the hospital director to say that there had been a “litany of basic errors” on the ward and that he had “no confidence” in staff to maintain safety under the observation policies. He described it as an “utter shambles”.
Priory Health Limited, which has a reputation for treating celebrities such as Kate Moss and Pete Doherty, pleaded guilty to failing to discharge a duty under Section 3(1) Health and Safety at Work Act 1974, after being prosecuted by the Health and Safety Executive.
Describing the fine as “disappointing”, Whyatt’s brother Daniel said: “We believe with all our hearts that the Priory Roehampton was an environment not at all conducive to Francesca’s recovery, quite the contrary, in fact.
“Francesca was there primarily because we were convinced by all the ‘experts’ that it was the only place for her, and that it would be a missed opportunity. The Priory have the best specialists in their field, allegedly.”
The court heard that Whyatt, one of quadruplet sisters, had suffered with her mental health since she was 13, and had previously been an inpatient at a hospital near her family home in Knutsford, Cheshire.
She was transferred to The Priory in March 2013, where she was placed on the Emerald Ward, a four-storey, female-only secure unit which specialised in personality disorders and psychosis.
Her brother said that Whyatt had told him “repeatedly” of staffing issues and the “havoc wreaked on a daily basis”, with agency staff frequently being replaced.
“Francesca wanted desperately to leave and begged me personally to get her out of there multiple times, you cannot imagine just how helpless we all felt,” he said.
In his letter to The Priory, Dr Lord listed 12 issues that had occurred in the days leading up to Whyatt’s death, which included the front door being left open on more than one occasion, a patient picking up a hacksaw, staff refusing to follow orders and a failure to uphold observation policies.
On 25 September, there were only two nurses with “limited experience” on shift, with five healthcare assistants also present to care for nine patients. Of the two nurses, the manager had only started the previous week, while the other was only on their second shift.
Over the course of that day, staff had to deal with two women who had tried to self-harm, with the police called to assist.
As a result, other patients were taken into the clinic. One patient absconded while Whyatt was able to re-enter the building unnoticed.
She was found less than a quarter of an hour later with fatal injuries, just a week after her 21st birthday. Her sister Jessica described her as a “ray of sunshine”, and added: “She put everyone before herself, even if she was having a bad day, she made sure everyone else came first. She was the baby of the family but also the protector.”
The family said that learning of other patients’ deaths in similar situations to Whyatt’s had only served as a heartbreaking reminder of the failures she had faced.
In 2019, the Priory Group was fined £300,000 over the death of 14-year-old Amy El-Keria, who was being treated at the Ticehurst House psychiatric hospital in East Sussex when she died in November 2012.
In her case, the court heard that untrained staff had failed to dial 999 quickly enough, staffing levels were inadequate and a ligature audit of her room which identified medium risks was not followed up.
The healthcare group was bought by the private equity group Waterland for £1.1bn in January 2021 and currently operates 290 facilities across the country.
Fining it £140,000 plus prosecution costs for Whyatt’s death, His Honour Judge Baumgartner said: “Her death was tragic and untimely. It came about because of a freak combination of events at the hospital caring for her.”
He added that Priory Hospital Roehampton had made “tangible changes”, with the Emerald Ward closing and reopening as a unit for eating disorders.
“No fine that I impose can ever reflect the truly awful loss suffered by Francesca’s family,” he said. “No family should ever go through a loss like that.”
A Priory spokesperson said: “We are deeply sorry that this tragic incident occurred at our hospital 10 years ago and we would like to express our heartfelt condolences to Francesca’s family for their loss.
“We take our responsibilities extremely seriously and, as recognised by the judge, have cooperated fully with the HSE’s investigation, entering a guilty plea at the earliest possible stage.
“The ward where Francesca was an inpatient closed in 2014, and we have made improvements to our observations and engagement policy. Since 2013, we have invested £15m into improving the environment, services and staffing at Roehampton Hospital.”
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