Before HM Coroner Sean Horstead and a jury
Essex Council Chambers, Chelmsford
28 February – 18 March 2022

Bethany Lilley was just 28 when she died whilst an informal patient on Thorpe Ward at Basildon Mental Health Unit, on the evening of 16 January 2019.  She was deemed to be at high risk of self-harm and suicide following multiple incidents, but had been put on lower observation levels before being found unresponsive.

A three week Article 2 inquest examining the circumstances of her death will open on Monday. This is one of a series of contentious deaths of patients in the care of Essex mental health services; prompting extensive campaigning of bereaved families and an ongoing independent inquiry.

Bethany was an ambitious young woman who had previously worked as a Health Care Assistant in a GP Surgery. She felt she had found her vocation in helping people and wanted to work in mental health care. However, Bethany experienced complex mental-health difficulties and had a diagnosis of Emotionally   Unstable Personality Disorder which ultimately impacted her ability to work.

Bethany had a history of psychiatric inpatient admissions, including being as a detained patient for a seven-month period between January and July 2018 (under Section 2 of the Mental Health Act 1983). Bethany’s condition significantly improved following this admission.

Unfortunately her mental health deteriorated again following the unexpected death of her father in October 2018. Between November 2018 and January 2019, Bethany had made multiple attempts of seriously self-harming. This resulted in no less than thirteen A&E attendances, and five separate psychiatric inpatient admissions, during the nine-week period immediately prior to her death.

Bethany continued to self-harm as a psychiatric inpatient, yet was consistently discharged within days of admission. Bethany’s final psychiatric inpatient admission was on 9 January 2019, just six days after her previous discharge. She was admitted as a voluntary patient at Peter Bruff Ward, Colchester.

From the evening of her admission, Bethany continued to display high risk and suicidal behaviour which included multiple ligature and self-harm incidents. One incident led to an A&E attendance.  Nonetheless, Bethany was still allowed to go on unescorted leave and on one occasion advised staff she had been a victim of a crime during this leave. She was therefore put under constant 1:1 observations (Level 3).

Bethany was transferred to Thorpe Ward, Basildon around midday on 15 January for continuing treatment. The ward did not receive all the relevant paperwork or case notes. Bethany was assessed by a psychiatrist upon arrival and put on a lower level of observations, requiring four observations an hour (Level 2), and a tentative discharge date in a week’s time was given.

Bethany was again permitted to go on unescorted leave the following day (16 January) arriving back on the ward at 18:00 and reporting feeling anxious. An hour and 45 minutes later she was found unresponsive in her shared room, with a ligature. Following resuscitation attempts she was declared dead at 20:36 on 16 January 2019.

The inquest will examine the circumstances of Bethany’s death and any issues in the care and treatment she received. The family have particular concerns they hope will be addressed, including:

• the overall treatment from Essex Partnership University Trust services,
• decisions to discharge Bethany from previous inpatient care,
• the sharing of important information upon transfer to Thorpe Ward,
• the monitoring and observations level on the ward,
• access to ligatures and dangerous items.

Speaking before the inquest, Bethany’s family said: “We have so many unanswered questions; why was Beth not being monitored closely? How did she come to have possession of an item she can use as a ligature when she was at a high risk of ligaturing, and had made a serious attempt on her life the night before her death? Why did the Trust keep discharging her when she was clearly so unwell? We are deeply concerned with the thought that this could happen to someone else.”

Jenny Fraser of Fosters’ Solicitors representing Bethany’s family said: “It is such a tragedy that Bethany has gone. Her family have lost a daughter, a sister and an aunty.  It is crucial that the family seek the answers they have been waiting for, seek justice for Bethany and that lessons are learnt to ensure that future patients are safe.”

Caroline Finney, Caseworker at INQUEST, said: “It is vital that this inquest gives Bethany’s family the answers they need about the care she received from Essex Partnership University Trust prior to her death. Hers is one of far too many deaths of people in the care of Essex mental health services in recent years. It is in the public interest to ensure any issues are identified by this inquest, in order to inform urgent change to prevent future deaths.”

ENDS

NOTES TO EDITORS

Enquiries should be directed to Jenny Fraser at Fosters’ Solicitors.  Telephone 01603 620508 or email [email protected]

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Other interested persons represented are Essex Partnership University NHS Foundation Trust.