Before Senior Coroner Crispin Butler
Beaconsfield Coroner’s Court Coroner

21 November 2018 – 6 December 2018

Mother of five Emma Butler, 33, died whilst sectioned as an in-patient on the Ruby Ward, Whiteleaf Centre, Ayelsbury, under the care of Oxford Health NHS Foundation Trust. Her death was the third self-inflicted death within 15 months to occur at the Whiteleaf Centre.

The inquest into her death has concluded, with the jury critical of the care and decision making which allowed her unsupervised leave, despite evidence of her risk of self-harm. 

The jury identified that the change of approach to the granting of leave to and the taking of leave by Emma during 2017 probably contributed to Emma’s death. In addition, the jury identified that the following factors possibly contributed to her death:

  • the change of approach to the care and discharge planning for Emma whilst an inpatient on Ruby Ward during 2017;
  • decisions about the leave on the afternoon of 28 March 2017.

The coroner noted that there was no evidence Emma intended to take her own life.

During the inquest it emerged that Emma had called the Ruby Ward telephone 15 minutes before she was found with the fatal injuries. Despite this call lasting for 1 minute and 9 seconds, it failed to appear in any of Emma’s medical records and her family still do not know which member of staff answered this call.

Emma had a history of mental ill health and serious self-harm and was diagnosed with depression aged 15. Following a five-year period of stability Emma was diagnosed with Emotionally Unstable Personality Disorder. She had been under the care of Community Mental Health Services since December 2015. In May 2016, shewas admitted to Ruby Ward at the Whiteleaf Centre under Section 2, then Section 3, of the Mental Health Act. 

On 28 March 2017, Emma was granted a one-hour unsupervised leave. This was despite ongoing events of self-harm and psychotic thoughts. She was later found in the car park of the Whiteleaf Centre having seriously self-harmed. She was transferred to hospital in Aylesbury and went into multiple organ failure. She was taken off life support on 30 March 2017.

The family of Emma Butler said: "Emma was beautiful on the inside as well as the outside. She had a heart of gold and would help anyone she could when she was well enough to do so. She was a warm, loving person with a good sense of humour. Emma’s children were her world and she absolutely adored and loved each and every one of them. She is very deeply missed.

The jury’s conclusion confirms what we have known about Emma’s care for the last 20 months. We hope that the Trust now makes the changes required so that no other family has to go through what we have had to go through.

We would like to thank Leigh Day for their support during this very difficult process.”

Sophie Wells, solicitor at Leigh Day said: "We are grateful for the diligence of the jury and for their recognition of the multiple failings in Emma’s care which contributed to her very sad death while an inpatient at the Whiteleaf Centre.

Inquests are incredibly distressing for any bereaved family, however Emma’s family had to endure a prolonged hearing after it emerged their daughter’s call to the ward before she was found with fatal injuries had been answered and lasted for over a minute. Emma had said she would call the ward if she needed support.

Although it is deeply unsatisfactory that no staff member can recall receiving Emma’s call, her family and I hope that changes will now be made that better protect other patients in the future.”

Merry Varney, Partner at Leigh Day added: “This is the third inquest in which I have recently represented the bereaved family of patients at the Whiteleaf Centre who died over the course of 15 months. All three inquests resulted in critical jury findings despite efforts by the Trust and their legal representatives to avoid some issues even going to the jury. In all three, the senior coroner expressed concerns about risks to future lives arising from the Trust’s policies and practices, publishing so far two Prevention of Future Death reports following the inquests into the deaths of Jack Portland, who died on 27 December 2015 while on unescorted leave, and Zoe Watts, who died in March 2017 having tied a ligature in her bedroom on Ruby Ward.

The concerns of each bereaved family had glaring similarities from lack of communication between staff and family, to failures in management of leave and care planning and these echo concerns raised across the country by other bereaved families in inquests of those receiving mental health care. Whilst Sir Simon Wessely’s recommendations for improving and updating the Mental Health Act are very welcome indeed, it is clear more must be done to prevent avoidable deaths of patients in mental health care and stop repeat failings arising.”

Victoria McNally, caseworker at INQUEST said: “We must question the systems of learning that have allowed three deaths at the same unit within a 15 month period, exposing such similar, basic patterns of failure. INQUEST has consistently called for a national body responsible for overseeing learning to prevent unnecessary deaths from failed learning. A call now echoed in recommendations from the recent independent Mental Health Act review, which we hope the Government will now hear and take up to stop such painful and unnecessary further tragedies.”



The family is represented by INQUEST Lawyers Group members Merry Varney and Sophie Wells of Leigh Day and Adam Wagner of Doughty Street Chambers.

Previous inquests have highlighted multiple failings at the Whiteleaf centre:

  • Zoe Watts, 19, was a patient on the same unit as Emma Butler. She died on 28 March 2017, as a result of self-inflicted injuries on 23 March 2017.
  • Jack Portland died on 27 December 2015 whilst a patient at the Whiteleaf Centre. The jury at the inquest found failings in the risk assessment process, communication with Jack’s family, the leave system and how they respond to patients absent without leave.

The Interested Persons represented in the inquest proceedings were Emma’s family, Oxfordshire Health NHS Foundation Trust (in charge of Whiteleaf Centre) and Buckinghamshire Healthcare NHS Trust (in charge of Stoke Mandeville Hospital).