2nd June 2016

West Sussex Coroner's Court sitting at Horsham before HMC P Schofield sitting as an Assistant Coroner

Late yesterday a jury at Horsham Coroner’s Court concluded the Priory's neglect (ie gross failings) contributed to the death of 14 year old Amy El-Keria during her admission as a mental health patient. 

Reaching their conclusion, the jury found the Priory failed to meet Amy's care needs or to properly manage her risk, identifying factors contributing to her death including:

  • inadequate staffing levels
  • failures to share key risk and care information with staff
  • inadequate systems for identifying and managing ligature risk, placing Amy in an unsuitable room containing high risk ligature points
  • missed opportunities for removing a scarf in Amy's possession (used by Amy as a ligature on the day of her death)
  • a failure to adequately address bullying of Amy by her peers or to follow the Priory's anti-bullying procedures
  • failures to pass key information about Amy's increased suicide risk on the day of her death and a failure to increase staff observations in response to that increased risk
  • delay in undertaking the final observation during which Amy was found hanging
  • failures in the emergency response including delays in calling an ambulance, contacting the duty doctor and commencing CPR
  • lack of training to enable staff to respond to an emergency situation

Amy El-Keria had complex health needs associated with multiple mental health diagnoses. Following several incidents involving her use of a ligature and two attempts to strangle herself at home, Amy was urgently referred by West London Mental Health Trust to Ticehurst House, East Sussex, where on the 24 August 2012 she was admitted as a patient to a specialist Child and Mental Health (CAMHS) High Dependency Unit.  Ticehurst is a private psychiatric hospital run by the Priory Group located two hours drive from Amy's family home. This was Amy's first admission to a psychiatric hospital.

At the time of her admission, Amy was deemed at high risk of self harm and suicide.  Her conditions were said to cause her difficulties with forming friendships with peers and she was known to be at risk of isolation.  Central to her care plan was daily provision for one to one personal time with staff, including to have bed time stories read to her at night.
Although a patient at Ticehurst House for less than three months, inquest evidence detailed six incidents of restraint several involving forced sedative injections applied against Amy's will.  The first restraint occurred within 2 days of Amy's arrival, involved 4 members of staff and lasted 15 minutes. On 25 September Amy was restrained on the floor by 3 staff for 17 minutes, sedated against her will and left sleeping on the floor.  On 28 September she was restrained on the floor by 4 staff and complained of being choked by her hood, the back of her head smashed against the floor and being kneed in the chest.  The last incident occurred the day before her death, when Amy was restrained by 5 members of staff for 15 minutes and orally sedated.
The jury heard evidence of the Priory's failure to notify Amy's mother of many of these incidents of restraint and forcible sedation, as well as incidents of self harm and suicide threats made to staff.

On 12 November, just after midnight, Amy told staff she had tried to hang herself saying I want one to one but no-one has time.  On the afternoon of 12 November, Amy told medical staff she wanted to hang herself.  This information failed to prompt a risk review, no search of Amy's room was carried out to check for and remove potential ligatures and there was no increase to the frequency of staff observations levels from the standard 15 minutes set for the duration of Amy's admission.
On the 12 November at approximately 20.17 a healthcare assistant found Amy’s bedroom locked (she was due to be checked at 20.12 according to the 15 minute observations regime in place). She returned with keys to access Amy’s room and found her collapsed on the floor with a scarf used as a ligature around her neck. CPR was not immediately commenced until arrival of the duty doctor. An ambulance was not called until 20.27.  Amy was transferred by ambulance to Conquest Hospital, Hastings but was never regained consciousness.  She was pronounced dead at 13.55 on the 13 November.  No staff travelled in the ambulance with Amy and it was not until Priory staff telephoned at 22.55 on 12 November that her family were informed.

Healthcare witnesses spoke of over-stretched staff working in over-pressured conditions, with insufficient time to meet the needs of the children on the unit: rarely getting breaks from continuous 1:1 observations not even toilet breaks, high reliance on agency staff including with no psychiatric experience, insufficient time to read patients key paperwork or clinical notes, poor communication and strained relationships between staff and management, lack of basic training. 

One Healthcare Assistant described her repeated requests for first aid training being ignored and feeling ill equipped to fulfil her role without this, with restraint training given only 8 or 9 months into post.  Another nurse resigned shortly after Amy's death, stating that he believed the organisation was responsible for Amy's death and that he felt Amy's suicide was avoidable had the unit been better resourced.

Amy’s family, the Priory, two individual doctors, West London Mental Health NHS Trust and London Borough of Hounslow Social Services were all represented as Interested Parties.

Tania El-Keria, Amy's mother said:
"Amy was my most loved youngest daughter, sister, niece and granddaughter with her whole life ahead of her.  She had a warm heart and a great sense of humour.  She never liked to see people treated unfairly and would be the first to stand and say "that's not right".

For14 years we kept Amy safe.  In less than three months under the care of the Priory she was dead.  The only thing that has kept me going since her death nearly four years ago has been the need to achieve justice for my Amy.   

I knew the Priory's investigation following death was a whitewash and this inquest has proven that.  If I had treated Amy and neglected her needs in the way Ticehurst house did she would have been taken away from me.

I don't blame junior staff for what happened to Amy, I blame the Priory for failing to put in place the systems needed to keep her safe and for ensuring she received the care and treatment she so desperately needed.

Had she lived, Amy would have turned 18 during this inquest hearing.   I am so sad that others will not have the privilege of meeting someone as caring, loving and exceptional as Amy.  The most important thing to me now is to change the system which is failing to provide the mental health care our children need.  I will continue this fight in my Amy's name."

Deborah Coles, Director of INQUEST, who have supported Amy’s family since her death, said:
“The jury findings are an indictment of a mental health system that placed a child far away from home, in a private unit operating dangerous and grossly inadequate systems of care The desperate catalogue of failings exposed at this inquest all point to a system that is shamefully failing our responsibilities of care for vulnerable children.

This evidence has only been exposed now, four years after Amy’s death, as a result of the family’s fight for a full inquest with a jury, resisted by the Priory.

We must question the marketization of children's mental health, with the lack of visibility and structures of accountability that this brings.

The only possible response to this case and the growing public outcry around mental health services for children and young people is for an urgent independent review. We call upon the Government to now take this necessary step. A failure to do so will almost certainly result in the further unnecessary deaths and suffering of more children.”

Tony Murphy, Family's Solicitor, Bhatt Murphy:
"The jury's powerful conclusions follow a four year battle by Amy's family to establish the truth. The disturbing circumstances of Amy's death reveal the dangers involved in the NHS outsourcing psychiatric care of vulnerable young people to remote private institutions." 

INQUEST has been working with the family of Amy El-Keria since shortly after her death.  The family is represented by INQUEST Lawyers Group members Tony Murphy, Bhatt Murphy solicitors and barrister Raj Desai of Matrix Chambers.




Notes to editors:

Over eleven days the jury heard evidence that: 

  • Staff involved with Amy's day to day care had little or no knowledge of the circumstances of her admission, were not made aware of the content of her care and risk plans, had insufficent time to read key paperwork and were largely dependent on handovers which failed to adequately communicate her difficulties and risk.
  • Amy's care plan ceased to be updated from mid October.  For a period of 3 weeks Amy was left without a Primary Nurse.
  • Information was copied and pasted from one risk assessment to another and some risk assessment plans incorrectly recorded Amy's risk as 'medium' instead of 'high'.
  • Although recognising the importance to Amy of receiving personal one to one engagement, staff pointed to a lack of staff time and capacity to meet these requirements of her care plan, even when this was specifically requested by Amy.
  • Staff lacked knowledge or training of basic policies relevant to all key areas of day to day care and risk planing.
  • Despite being identified as at high risk of self harm and suicide using a ligature, Amy was placed in a "dangerous" room with known high risk ligature points (those ligature points were not made known to staff responsible for her day to day care).
  • Despite being recognised as a high risk item, Amy was left in possession of a large red football scarf which she able to use as a ligature on the day she died.
  • Disturbed by the messy state of her bedroom, a family member had taken a photo of Amy's room on 27 October, which shows a red football scarf in plain sight on her desk.

Other background information:

  • Amy El-Keria is one of at least 11 child deaths of mental health in-patients INQUEST has identified over the period 2010 to 2014 through its casework and through the conduct of an extensive FOI exercise. See more here
  • The case of Sara Green, a 17 year old who also died following ligature in a Priory Hospital, also raised concerns around the Priory’s systems of practice and care. See more here
  • INQUEST’s report ‘Deaths in Mental Health Detention: An investigation framework fit for purpose?’ can be accessed here.
  • Through its research, INQUEST has established that no single body is responsible for recording the deaths of children who die as mental health in-patients. This crucial information is neither collated nor analysed or made public by any one body or government department;
  • INQUEST met with Alistair Burt, Minister for Health, on 21 April 2016, to discuss some of the issues raised through INQUEST’s research.
  • Approximately 47% of all in-patient child and adolescent mental health services are now provided by private providers, including the Priory.
  • There is currently no pre inquest system of independent investigation into the deaths of children who die as mental health in-patients.  In Amy El-Keria’s case, the ‘Serious Incident Investigation’ (not yet published) reviewing the care and treatment received and the circumstances surrounding her death was conducted by the Dr Hamilton Mc Brien, a CAMHS Specialist Consultant at the Priory Hospital North London
  • A photo of Amy is available upon request


Source: INQUEST Casework and monitoring

For further information, please contact: Victoria McNally or Deborah Coles, INQUEST, 020 7263 1111.