1 July 2021

Before HM Senior Coroner Tom Osbourne
Milton Keynes Coroner’s Court
21 June - 1 July 2021

An inquest jury has found that serious failures of risk assessment, communication, and the setting of observation levels contributed to the death of 19-year-old Brooke Martin on 11 June 2019.

Brooke, who had diagnoses of Autism and Emotionally Unstable Personality Disorder, was detained under the Mental Health Act at Chadwick Lodge Hospital run by Elysium Healthcare when she died. Brooke, described as a caring, thoughtful and clever young woman by her family, had a chronic history of life-threatening self-harm.

Reaching their conclusion, the jury found that Elysium Healthcare failed to properly manage Brooke’s risk, identifying factors contributing to her death as:

  • The failure of staff to communicate information regarding an incident five days prior to her death when Brooke was found suspended from a ligature in her room;
  • The failure of staff to search Brooke’s room after she was found handling potential ligatures on the night she died;
  • The failure of staff to increase Brooke’s level of observations to constant observations when she was found handling potential ligatures on the night she died.

Brooke, from Godalming in Surrey, was found unresponsive by staff on the evening of 10 June 2019 having suspended herself from a ligature in her hospital bedroom; she was later pronounced dead at Milton Keynes University Hospital.

The inquest heard that earlier that evening Brooke was twice found by staff to be handling an item which could be used as a ligature which she had concealed under her duvet. The staff members failed to re-assess Brooke’s risk, to place her on constant observations, or to search her room for potential ligatures in response.

Evidence was heard that Brooke had previously suspended herself from a ligature only five days earlier on 5 June 2019. It was accepted by healthcare witnesses that this incident was a ‘massive red flag’ and an ‘alarm’. However, it was not properly recorded or communicated between staff and as a result did not trigger a risk assessment or review of Brooke’s observations.

The inquest heard that the ward was ‘chaotic’ on 5 June 2019, when four serious incidents occurred simultaneously. At the Multi-Disciplinary Team meeting the following day it was not communicated that Brooke had applied a suspended ligature. Further, a ‘glitch’ affecting the computer system meant that the record of this incident was not available to staff within Brooke’s medical records. As a result staff treating Brooke on the day of her death were unaware that this earlier incident had taken place.

On the day of her death Brooke presented as overwhelmed and distressed. However this information was not handed over from the day to the night staff.

Elysium formally admitted during the inquest that when Brooke was twice found with potential ligatures on the night of her death these should have been removed from her, a risk assessment conducted, and Brooke placed on constant observations. Elysium accepted that had this action been taken Brooke would not have died. Elysium further accepted that, following the incident on 5 June 2019, Brooke’s risk should have been re-assessed and information about the incident communicated to staff treating her.

The inquest jury concluded that Brooke took her own life while suffering from a mental illness, namely Emotionally Unstable Personality Disorder.

The coroner confirmed that he would write a report, intended to prevent future deaths, to the Secretary of State for Health and Social Care concerning inadequacies in the systems in place for the sharing of medical records between healthcare providers. He confirmed that he would also raise the issue of the introduction of anti-ligature pressure sensors in mental health settings at the Milton Keynes Together multi-agency safeguarding group and with other coroners nationwide.

Brooke had begun to experience mental illness in her early teenage years.  Her mental health deteriorated markedly during the 18 months prior to her death, resulting in numerous serious incidents of self-harm and periods of detention under the Mental Health Act. The inquest heard that the severity of Brooke’s self-harming was such that between April 2018 and February 2019 she required medical treatment at one local A&E department on 39 separate occasions.

Between December 2018 and April 2019 Brooke was detained for treatment at Farnham Road Hospital in Guildford, which is run by Surrey and Borders Partnership NHS Foundation Trust. In April 2019, Brooke was transferred to Chadwick Lodge Hospital. The inquest heard that although during her first month at Chadwick Lodge Brooke had found it difficult to settle, she was showing a ‘remarkable’ improvement by the time of her death.

A referral was being progressed for her to move to Hope House, a separate unit within the same hospital which delivers specialist therapy to treat Emotionally Unstable Personality Disorder. During the days before her death Brooke, whose long-term ambition was to become a vet, told staff that she was eager to move to Hope House and engage in the therapy offered there.

Natasha Darbon, Brooke’s mother, said: “Brooke was a kind, clever woman and my best friend. I feel so incredibly sad that she is no longer here. As a family we did our best to keep Brooke safe in the community, but eventually the risk she would harm herself became too much for us to cope with. We thought it was a positive step when Brooke was admitted to hospital because she would finally receive the help she needed and in the meantime she would be kept safe by professionals with the necessary expertise.

As a family we have been utterly shocked to learn of the inadequacies in the care provided to Brooke at Chadwick Lodge, and that opportunities to save her life were repeatedly missed by those entrusted with her care. I would like to thank the coroner and the jury for considering the evidence. I sincerely hope that lessons will be learned so that no other family has to lose a loved one in such tragic circumstances.”

Paul Martin, Brooke’s grandfather, said: "Brooke wasn't just a hospital reference number or a statistic, she was a much loved daughter and granddaughter. Not only has a generous spirit been lost but my opportunity to have great grandchildren. The unjust nature of her death is totally unacceptable. Despite her illness she was fighting to get better and move on to Hope House. The phrase ‘missed opportunity’ doesn’t do justice to the seriousness of the failures. I write this not just for myself but for all families that have to endure such injustice and the loss of loved ones in these circumstances. Lessons desperately need to be learned.”

Catherine Shannon of Bhatt Murphy solicitors and Stephen Clark of Garden Court Chambers, who represent the family, said: “Brooke was detained under Section 3 of the Mental Health Act when she died; she had a chronic history of life-threatening self-harm. This inquest has revealed stark failures in risk assessment, information sharing and observation setting in a mental health hospital dealing with an exceptionally vulnerable patient group.”

Selen Cavcav, Senior Caseworker at INQUEST, who works with the family, said: “Brooke was a young woman with the potential to get better. She had a supportive family who kept her safe, despite the challenges posed by her mental ill health. Yet within months of being admitted to this privately run facility she had died.

At the time of her death Brooke was waiting for a transfer to Hope House, a facility offering specialist therapy for her needs. The lack of appropriate and safe units for young women with complex mental health needs, such as personality disorders, is a serious issue costing far too many lives.

It is particularly frustrating to see the failings identified by this inquest echoed in so many others. Poor communication and a lack of active risk assessment causes deaths around the country. Yet the mechanism for responding to recommendations arising from inquests is ineffective. A mechanism for national oversight on deaths in places of detention is much needed and long overdue.”


For further information please contact Lucy McKay on 020 7263 1111 or [email protected]

Brooke’s family are represented by INQUEST Lawyers Group members Catherine Shannon of Bhatt Murphy solicitors, and Stephen Clark from Garden Court Chambers. The family are supported by INQUEST caseworker Selen Cavcav.

Other Interested persons represented are Elysium Healthcare, Surrey and Borders Partnership NHS Foundation Trust and the Care Quality Commission.

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

Elysium Healthcare Ltd: The provider were also criticised by a Safeguarding Adults Board following the death of Laura Davis, who was 22 when she died a self-inflicted death in Arbury Court, one of Elysium’s facilities in Warrington. Laura too was awaiting transfer to a more suitable placement, and had been able to access items which she used to self-harm. See media release.

Chadwick Lodge: Anthony McManus, 48, died at Chadwick Lodge on 31 October 2016, when it was run by The Priory Group. He had a personality disorder and learning difficulties, and had been a resident for a number of years. Following his inquest the coroner wrote a report to prevent future deaths, highlighting issues with the system of observations of patients.


Anti-ligature pressure sensors: In a prevention of future deaths report from March 2021, following the inquest into the death of Azra Parveen Hussain, HM Coroner for Birmingham and Solihull recommended that pressure sensor alarms to be placed on doors within areas where patients are afforded privacy and time alone. These sensors had been available in the country for ten years but are currently not in use at Chadwick Lodge. The significance of doors as potential ligature points in mental health settings is well known.