Before HM Assistant Coroner Sean Horstead
Sussex Central Cricket Ground

Opens on 11 November, expected to last for 2 weeks

Bethany Tenquist, 26, was found unconscious with self-inflicted injuries in her room on the Caburn Ward at Mill View Hospital in Hove on 29 December 2018. She was an inpatient detained under the Mental Health Act (section 3). She died two and a half weeks later on 16 January 2019 at Royal Sussex Hospital. The inquest into her death opens on Monday.

Bethany, known to her family as Beth, was from Brighton and was a trainee nurse, painter, animal lover, chef and gardener. Her family describe her as having a joyful and bubbly personality and a natural talent and love for music and the arts. At age 16 Beth began to develop an eating disorder, after experiencing a series of traumatic events. When she was 20, Beth was referred to an eating disorder clinic and was diagnosed with Emotional Unstable Personality Disorder.

From September 2017 onwards Beth had numerous involuntary inpatient admissions, arising from her risk of suicide and serious incidents of self-harm. By this time, she had developed alcohol dependencies. Beth’s final inpatient admission to the Caburn Ward was on 18 September 2018. During this admission, Beth absconded from hospital on multiple occasions and reported bullying by other inpatients.

Beth’s family would like the inquest into her death to explore the following issues:

  • the actions taken by Mill View Hospital to safeguard Beth against bullying;
  • the adherence to policies on contraband and the adequacy of searches undertaken;
  • the staffing levels on the ward, specifically concerning whether there was sufficient oversight of junior or non-medical staff by psychiatrists.

Mill View Hospital is run by Sussex Partnership NHS Foundation Trust. At a pre-inquest review hearing on 20 March 2019, HM Senior Coroner Veronica Hamilton-Deely, who opened Beth’s inquest, was so concerned about the care of patients at Mill View Hospital that she wrote a report to prevent future deaths before hearing any live evidence. This inquest will now be heard before Assistant Coroner Sean Horstead.



For more information contact the INQUEST Communications Team on 020 7263 1111 or Lucy McKay and Sarah Uncles on [email protected] and [email protected]

INQUEST has been working with the family of Bethany Tenquist since March 2019. The family is represented by INQUEST Lawyers Group member Basmah Sahib of Bindmans Solicitors and Allison Munroe from Garden Court Chambers.

The other Interested Person represented at the inquest is Sussex Partnership NHS Foundation Trust.

The Prevention of Future Deaths report expressed a series of concerns including that vulnerable patients were continuing to self harm and that checks and the removal of items considered dangerous to patients was incomplete and flawed.

Other deaths at Mill View Hospital

  • Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care, including incomplete, insufficient and at times contradictory nursing records, handovers, risk assessment and care plan and a failure by hospital administration to provide sufficient staff. Media release.

We are also aware of a number of other deaths relating to the same ward, as reported in local press.

Other deaths under the care of Sussex Partnership NHS Foundation Trust

  • Sabrina Walsh, 32, died on the Woodlands Ward in 2016. The jury found gross failures and neglect contributed to her death. Media release, July 2017.