17 May 2024

This is a media release by Irwin Mitchell, reshared by INQUEST

Grieving parents are campaigning for improved women’s mental health services nationally following the death of their daughter who had been detained on a psychiatric intensive care unit for 13 months. 

Amina Ismail was found fatally injured in her room on the Pankhurst Ward, a psychiatric intensive care unit (PICU), at Priory Hospital Cheadle Royal near Stockport on 15 September, 2023. Emergency services were called but she was pronounced dead shortly afterwards. 

The 20-year-old, originally from Balsall Heath, Birmingham, had been detained in the privately-owned Priory Group hospital under the Mental Health Act since August 2022. She had been known to mental health services since the age of 15. 

Amina had been diagnosed with emotionally unstable personality disorder (EUPD), post-traumatic stress disorder and disordered eating, was detained on at least seven different mental health wards between 2019 and 2023, all of which were out-of-area placements.  

Following Amina’s death, her parents Ahmed and Roda, instructed specialist lawyers at Irwin Mitchell to help support them through an inquest and secure answers.

Amina’s family and their legal team are now calling for action to tackle a national shortage of appropriate placements to help young people, particularly women, with complex mental health needs. 

It comes after an inquest jury at South Manchester Coroner’s Court concluded Amina died by misadventure, contributed to by a prolonged 13-month stay on the PICU due to a shortage of appropriate placements. 

Coroner Andrew Bridgman said he now intended to issue a prevention of future deaths report calling on the government and NHS England to set out what measures it will take to improve the availability of appropriate mental health placements. 

Alexander Terry is a public law and human rights lawyer at Irwin Mitchell. He said: “Amina’s story is yet another tragedy involving a young woman with complex mental health needs losing her life while detained miles from her home and her family.

“The last four weeks and listening to the evidence has been incredibly upsetting for them, but they’ve shown great strength and dignity in fighting for the answers that they, and Amina, deserve.

“Sadly, the inquest has validated the family’s concerns and identified that the prolonged stay on the PICU as a result of the national shortage of appropriate specialist beds contributed to Amina’s death.

“Amina’s loved ones still believe that if she had received the care she should have then she may still be with them today.

“We welcome the coroner’s intention to issue a prevention of future deaths report to the Secretary of State for Health and NHS England. What this hearing has highlighted is that there’s a national shortage of appropriate rehabilitation placements for vulnerable young women with emotionally unstable personality disorder or complex trauma.

“Amina was ready for a step-down placement a year prior to her death, yet she remained in an out of area hospital for a total of 13 months. This inquest has heard evidence about the problems that out-of-area placements create for the planning and delivery of care.

“This inquest has also heard evidence about how heavily the NHS relies on the private sector to provide mental health beds. The current system prioritises profit at the expense of patient well-being.

“The Government pledged to end out-of-area hospital placements by 2021. By failing to deliver on this pledge, the state continues to fail some of the most vulnerable young people in this country.

“We continue to support Amina’s loved ones and will do all we can to help them obtain justice.”

Amina was admitted to Priory Cheadle Royal’s Pankhurst Ward, a PICU, in August 2022. 

At the time of her death, Amina had been waiting for a step-down placement for approximately a year. Much of the inquest has focused on the negative impact of that delay on Amina.  

Speaking on behalf of the family after the inquest, Ahmed said: “Amina was a wonderful daughter and sister. She was very gifted and had ambitions of becoming a nurse or a paramedic. She also enjoyed art, especially painting.

“The last year was a real struggle for Amina. She was miles away from home and despite us visiting and supporting her as much as we could, we felt she was isolated. All we desperately wanted was to at least to get her closer to home and then back to her family.   

“It’s almost impossible to describe the hurt and pain we’re going through following Amina’s death. She had her whole life ahead of her and it devastates us that she’s no longer with us and she’ll never get to fulfil her potential and ambitions. 

“It’s a reflection of our mental health system that Amina was in and out of placements and moved from pillar to post for years, while we feel, never really getting the help and support she needed. 

“If she had then we wouldn’t have had to go through the trauma of losing her and the trauma of trying to establish answers in her memory. 

“We thank the jury for returning a verdict of misadventure and for recognising the systemic issues which contributed to Amina’s death.  

“All we can hope for now is that lessons are learned from how Amina was let down. It’s imperative that changes are made to how people with mental illnesses, and particularly young women, are cared for. 

“The current system isn’t equipped to deal with our most vulnerable and has to change for the better.”

Selen Cavcav, Senior Caseworker at INQUEST, said: “The fact that Amina with her known vulnerabilities and risks was sent into a private unit where there has been repeated deaths in similar circumstances, speaks volumes about the haphazard way these decisions are made at a corporate level.   

The  gap in the availability of specialist care beds especially for young women with EUPD,   should not mean that the contracts should be handed out to private providers with a shameful track record of neglect and criminally unsafe practices.”

Amina’s family were represented at the inquest by Kate Stone of Garden Court North. 

Find out more about Irwin Mitchell's expertise in supporting families concerned about the care their loved ones are receiving at our dedicated protecting your rights section. Alternatively, to speak to an expert contact us or call 0808 231 2767.