23rd June 2017

Surrey and Borders Partnership NHS Foundation trust has been sentenced to a fine of £300,000 after pleading guilty to maintaining an unsafe environment at the Langley Unit mental health facility. That failure led directly to the death of 20-year-old Adam Withers on 9 May 2014, who fell 130ft to his death whilst in the grip of a mental illness.

His death is part of an ongoing pattern of failures in secure mental health wards, including in the Elgar Ward in Epsom Hospital where Adam died. Last week the inquest into the death of Janet Müller, 21 who was killed after absconding from a Sussex Partnership NHS Foundation Trust ward found similar failures. For further information and cases see notes to editors.

The family of Adam Withers said:
“Adam Withers was my only son.  He was also a twin brother, and a baby brother.  He was a very special young man, with plans and hopes which were cut short just past his 20th birthday.  When Adam became ill, we trusted that he would be taken care of by Surrey & Borders – that they would provide quality nursing care and a safe environment.  We have learned from the inquest and now this prosecution that they failed on both counts. 

In one health and safety inspection after another, it was noted that the ward where Adam was held was inherently unsafe, but nothing was done until after he died.  Nursing staff seemed indifferent and passive, and I say this as a nurse myself.  We have watched the buck being passed up the chain and back down again for these failings. 

The inquest jury was highly critical of Surrey & Borders, and they have now pleaded guilty to keeping my son on an unsafe ward, for which they will pay a fine out of public funds.  The Chief Executive has apologised in a letter to my family. 

But there have been other deaths from the same unit; followed by Coroner’s recommendations and the inevitable responses from the Trust saying that “lessons have been learned”.  Clearly they were not.  I am calling on the Chief Executive to acknowledge, publicly, that the care offered to my son fell far short of what we were entitled to expect and that there is a history of poor care which needs to be addressed.  I am calling on her to stake her job on improvements being made. 

I also want to thank the caseworkers at the charity INQUEST, and Bhatt Murphy solicitors, for helping my family through this incredibly difficult and distressing time."

Deborah Coles, director of INQUEST said:
“The circumstances of this case show that the systems of inspection and regulation of mental health units fall dangerously short of ensuring that warnings and recommendations are acted upon, and real changes are made to safeguard the lives of patients. There isn’t a week that goes past when we are not contacted by a family following a death in a mental health unit. One common thing that they will all tell us is: ‘I thought he/she would at least be safe in a hospital’. Whilst the decision to fine the trust on health and safety guards is welcomed, what is needed is more funding into our mental health services and mechanisms to make sure that there is real accountability and learning to ensure that our mental health units are safe.”

The lawyer for the family Carolynn Gallwey from Bhatt Murphy solicitors said:
“Adam's family have lost a much beloved son and brother where this simply need not have occurred. For too long, mental health services have been treated as the poor cousin of the NHS and this is no better illustrated than in this tragic death where the quality of nursing care was poor and the physical environment was manifestly unsafe. Worse, the trust had been warned a number of times about the failure of staff to properly assess risk and about the unsafe construction of the Ward. 
This government has pledged to improve the quality of mental health services but without proper resourcing that is a cynical and empty promise.  The Withers family call upon the Chief Executive of the Trust, and the Secretary of State for Health, to publicly apologise and acknowledge the failures that led to Adam's death, and to commit to properly funding mental health services so that no other family need suffer as they have done.”

INQUEST has been working with the family since May 2014.  Family is represented by INQUEST lawyers Group member Carolynn Gallwey of  Bhatt Murphy Solicitors and barrister Chris Walker from Old Square Chambers.


For further information, please contact Selen Cavcav on [email protected] or 020 7263 1111

1. Full information on the circumstances and inquest findings of the death of Adam Withers can be found here.

2. Other similar cases include:
 Janet Müller, 21 (see above).
 Natalie Gray, 24 who died on 21st April 2015 while on home leave from Kent and Medway NHS and Social Care Partnership Trust ward. An inquest jury concluded that neglect contributed to her death.
 Abbi McAllister, 23 who was a secure inpatient on a Birmingham & Solihull Mental Health NHS Foundation Trust ward who died on 16 April 2015 after absconding during an off-site appointment. An inquest jury concluded that neglect contributed to her death.