18 December 2018

Before HM Senior Coroner Sarah Ormond-Walshe
South London Coroners Court
Opened 3 December – concluded 14 December

Catherine Horton was an inpatient in South London and Maudsley (SLAM) run Bethlem Royal Hospital. She died of self-inflicted injuries at her home in Croydon on 24 July 2017, two weeks after absconding from the Gresham 1 Ward. An inquest jury has concluded that she died from suicide, contributed to by neglect on the part of the medical and nursing team responsible for her care.

Catherine was 49 years old. Her family describe her as a warm hearted, gentle, funny, and free-spirited person. Catherine had been diagnosed with paranoid schizophrenia. She was detained under section 3 of the Mental Health Act 1983 when she absconded from the ward on 10 July 2017. She was sighted by several members of the public near her home.

Catherine managed to abscond from the ward, which was supposed to be locked and secure, for the first time on 10 June 2017. On this occasion she was returned to the ward by police. Despite this incident, no formal risk assessment was undertaken, and no investigation was conducted to ascertain how she managed to leave the ward.

The inquest heard that nurses and care assistants on the night shift of 9-10 July 2017 failed to complete regular checks on Catherine, allowing her to abscond at 1:36am. Despite this, they continued to fill in observation sheets suggesting Catherine was on the ward until the morning – resulting in the hospital not being aware that she had absconded for some seven hours. Four staff were suspended and two were referred to the Nursing and Midwifery Council for disciplinary proceedings, which are ongoing.

Despite Catherine passing a number of notes to staff throughout her stay on the ward suggesting suicidal ideation, expressing that she wanted to be dead and asking staff to kill her, no adequate attempts were made to assess Catherine’s mood, and she was considered to be at “no risk” of suicide or self-harm. Consequently, Catherine's notes indicating her state of mind were not passed to the police conducting the missing persons investigation.

The jury concluded that Catherine died of suicide, contributed to by neglect. They found that the circumstances which contributed to Catherine's death were that:

  • There was a failure by ward staff on night shift duty from 9–10 July 2017 to adequately observe Catherine, note her absence and report her absconsion;
  • The administrative electronic patient notes (EPJS) were ineffective in recording the date of receipt and content of notes Catherine handed to staff. These notes were known to be Catherine's primary method of communication whilst on the ward. They failed to be correctly fed into the relevant patient notes and reports;
  • Catherine's risk assessment had not been correctly updated and did not accurately reflect the risks that were relevant in her care:
  • The 'grab pack', a file of notes intended to inform police of all essential information about Catherine and assist in their search and response, prepared on the 10 July 2017 was unacceptable and contained serious omissions and inaccuracies;
  • The management structure of the ward failed to provide adequate leadership and to correctly delegate responsibility to individuals to coordinate the safe return of Catherine to the ward; and
  • There was a deficiency in the understanding of how to execute the warrant which allows access to properties and the return of inpatients who have absconded - known as section 135(2), once it was obtained. This led to an unacceptably long period of time between obtaining and executing the warrant.

During nearly two weeks of evidence the jury at Catherine’s inquest heard evidence that contrary to Trust policy, no formal risk assessment was undertaken, nor a care plan completed for Catherine when she arrived on Gresham 1 ward on 30 May 2017, or during her entire stay there.

Evidence was also heard that Catherine’s Responsible Clinician, a locum consultant psychiatrist who had only been on the ward for four weeks when Catherine went missing, was not aware of her medical history of distressing side-effects when he doubled her dose of anti-psychotic medication to the maximum dose. The Coroner’s expert witness, consultant psychiatrist Professor Keith Rix, stated this “might have made her illness worse”.

Professor Rix also expressed concern about the quality of nursing records throughout Catherine's admission, with observations appearing to have been simply copied and pasted, or conveying inadequate information.

As well as considering the actions of medical staff, the inquest also heard that the Metropolitan Police Missing Persons Unit was seriously understaffed and lacking resources at a time of significantly increased case load. The police accepted that the Missing Persons Investigation Report had been inappropriately closed, contrary to force policy, before Catherine was confirmed to be safe and well (although it was not ultimately causative of her death).

The Senior Coroner, Sarah Ormond-Walshe indicated that she would be making a Prevention of Future Deaths Report in relation to the lack of adequate resources for missing persons investigations by the police.

Lizzie Horton, Catherine’s sister said: “Catherine always said that she did not want help from the mental health services as they made things worse for her, and now that point’s been proved. The inquest has concluded very starkly that Catherine would still be here, were it not for the abysmal treatment that she received at Bethlem Royal Hospital. That is very difficult for us to hear. 

Someone very vulnerable, gentle and spiritual has had their life shortened as a result of failings by an organisation that wields power over those who are vulnerable, and that should have protected her.  When that power is combined with gross failings, I call that abuse of power. Please don’t allow this abuse to continue.”

Chanel Dolcy of Bhatt Murphy Solicitors who represented the family said: “The jury's conclusions clearly reflect the totally inadequate care provided to Catherine and the poor governance and failures in the systems that contributed to her death. This inquest has revealed extremely concerning evidence, especially surrounding the failure to complete observations and the untenable delays of returning Catherine safely to the hospital. This was a wholly unavoidable and unnecessary tragedy.”

Deborah Coles, Director of INQUEST said: “It is hard to believe that a woman detained for her own safety, who had already absconded, was able to walk out of a mental health ward and return home. But it is truly inconceivable that despite family and neighbours reporting her whereabouts, it took two weeks to get to Catherine. By then it was far too late.

We are glad this inquest has recognised the gross failures which contributed to Catherine’s preventable death. This is a hospital and mental health trust blighted with previous failures. Bethlem Royal and SLAM desperately need to address a culture of ineffective care and neglect.”


For further information and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected] 

INQUEST has been working with the family of Catherine Horton since September 2017. The family is represented by INQUEST Lawyers Group members Chanel Dolcy of Bhatt Murphy Solicitors and Tom Stoate of Garden Court Chambers.

Previous deaths in Bethlem Royal Hospital include:

  • Rosie Flett, 21, was a detained inpatient also on Gresham 1 Ward Bethlem Royal Hospital when she died on 11 February 2017. The inquest found searches and observations were not effective in locating blades used for self-harm, despite five previous incidents of cutting. The Coroner Selena Lynch wrote a Prevention of Future Deaths report in May 2018.
  • A.H., 27, was a detained inpatient at Bethlem Royal Hospital when she was on unescorted leave and died on 18 August 2016. The inquest in May 2017 found failings in the hospital’s recording and updating of risk assessment, and that adequate steps were not taken to ensure she had taken necessary medication.
  • Christopher Brennan, 15, was a voluntary patient at Royal Bethlem Hospital adolescent unit. On 21st September 2016 an inquest found his death was also contributed to by neglect. The inquest also found cumulative and continuing failures in risk assessment. Coroner Selena Lynch wrote a Prevention of Future Deaths report in December 2016.
  • Olaseni ‘Seni’ Lewis, 23, was a voluntary patient at Royal Bethlem Hospital and died on 31 August 2010. An inquest found multiple failures at multiple levels within the hospital meant that the staff had to call upon the assistance of the police when he became unwell. Seni was excessively restrained by 11 police officers as medical staff stood by.

This is in addition to numerous deaths of inpatients at other South London and Maudsley Trust hospitals such as the Maudsley Hospital.