Inquest into death of Linsay Bushell identifies multiple failings
Media release by Jackson Canter solicitors
The inquest into the death of Linsay Bushell concluded on 25th April 2017 after hearing two days of evidence. Miss Bushell died on 13th October 2014 at the age of 37. Miss Bushell unfortunately suffered the majority of her life from an Emotional Unstable Personality Disorder.
Miss Bushell was admitted to the Brunswick Ward, Broadoak Unit at Broadgreen Hospital in January 2014. Miss Bushell repeatedly self-harmed but sadly her risk was not adequately managed on the Unit.
On 13th October 2014 Miss Bushell was found under her bed with a ligature tied around her neck. Paramedics were called but regrettably they could not revive her.
The Broadoak Unit is under the care and management of Mersey Care NHS Trust. Miss Bushell’s death triggered an internal investigation in relation to the treatment/lack of treatment Miss Bushell received.
Mersey Care Trust accepted responsibility for Linsay’s death. They also admitted a plethora of failings including:
• a service that was psychologically driven was not provided
• the attempts to understand the motivation for self-harming behaviour was inadequate
• there was no focus or drive in finding Linsay the appropriate accommodation that would provide to her the appropriate and correct treatment
• staff were not sufficiently trained and/or supported to deal with Borderline Personality Disorder
• there was no, or a lack of, checking patients after a handover of information when the staff were changing.
• The handover documentation was scant
• The documentation of observation levels was insufficiently clear
The Jury returned a conclusion of accidental death and included the above criticisms and failings in the record of Inquest.
Due to these catastrophic failings, Mersey Care Trust have implemented new systems ensuring that staff are trained adequately and sufficiently to deal with Borderline Personality Disorders.
The Senior Coroner for the Liverpool and Wirral Coroner Area, André Rebello will be producing a Preventing Future Deaths Report as a result of Linsay’s tragic death. This report will be provided to the Secretary of State for Health along with the Care Quality Commission, Mind- Mental Health Charity and Borderline Personality Disorder Charity.
Leanne Dunne, solicitor representing the family said:
“It is a sad situation that we are repeatedly seeing the same basic failings for patients under the care of Mersey Care such as poor record keeping and observations. These issues continuing to arise in deaths which have occurred since Linsay’s death.
Unfortunately, vulnerable people are still at risk. It is vital that individuals with Borderline Personality Disorder do not go unnoticed and receive the appropriate care they need.”
The family of Linsay Bushell said:
“Linsay was a kind, caring and loveable person. She had to manage with this disorder for the majority of her life. We miss her every day and we will continue to miss her. Linsay was never in the correct place with the skills and experience she needed to manage for her needs and risks The entire system has failed Linsay and we are happy the jury recognised this. It is essential and necessary that drastic changes are made to mental health services and in particular in relation to Borderline Personality Disorder. We do not want families to go through this same tragic situation.”
‘I was already working with INQUEST, which is the organisation who monitor deaths in custody, and at one AGM I told the audience that what happened to these people [killed in police custody like Chistopher Alder, Roger Sylvester and many others] could happen to any of us. And then a couple of years later, I was standing in front of them again but now it had happened to my cousin. So my family and me were now “users” of Inquest. It shows you that none of us are immune – here am I, Benjamin Zephaniah, patron of INQUEST and client of INQUEST at the same time.’
– Benjamin Zephaniah