18 March 2022

Before HM Coroner Catherine Wood and a jury
Kent and Medway Coroner’s Court
10 – 18 March 2022

Emma Pring was 29 when she died after ligaturing whilst an inpatient at the privately run Cygnet Hospital Maidstone on 20 April 2021. An inquest into her death today concluded that the misjudgement of her risk by those caring for her, and their failure to properly observe her, contributed to her death.

BACKGROUND

Emma lived in Uckfield, East Sussex. Her family describe her as a loyal and generous person who put others first, and had an infectious smile and laugh. Emma had a history of mental ill health, including a diagnosis of depression, Emotionally Unstable Personality Disorder and Post Traumatic Stress Disorder. Her health and emotional challenges were caused by being raped in two separate incidents when she was 18. 

 In April 2016, Emma’s mental health declined further. After an overdose she began receiving care from Sussex Partnership NHS Trust. Around this time Emma left her job as a nursery nurse. In the following years she had multiple stays in mental health hospitals, both as a detained and voluntary patient, and was supported between admissions by the community mental health team. 

In November 2019, Emma was experiencing suicidal thoughts and was admitted to hospital, initially as an informal patient then as a detained patient (for treatment under section 3 of the Mental Health Act).

On 23 July 2020, Emma was transferred to Roseacre Ward at Cygnet Hospital Maidstone, for long-term specialist treatment to address the trauma she had experienced. At Cygnet, Emma remained detained under section 3 of the Mental Health Act 1983.

THE INQUEST

Cygnet Hospital in Maidstone are one of a very small number of hospitals who provide specialist treatment for women who have experienced trauma. Emma was offered two types of therapy at Cygnet: Dialectical Behavioural Therapy (“DBT”) with nursing staff and prolonged exposure with a psychologist.

On 5 October 2020, Emma started DBT. The jury heard that this type of specialist treatment was supposed to provide Emma with the skills (such as mindfulness, emotional regulation and distress tolerance) that she needed to cope with the trauma therapy.

Although Emma desperately wanted to have trauma therapy in order to overcome her trauma and live a fulfilled life, Emma’s mother told the jury that she was “terrified” of starting it. She knew that it would involve re-living her experiences of being raped as a young woman. 

Emma started the prolonged exposure therapy with a psychologist on 3 March 2020. At around this time, the jury heard that Emma began to disengage with the DBT by being absent at DBT skills group and not completing her homework. She told multiple members of staff on the ward, and her mother, that she was struggling with the trauma therapy. 

On 14 April 2021, six days before her death, Emma had started the “prolonged imaginal phase” of the trauma therapy which involved re-living being raped at the age of 18. Emma found this phase of her trauma therapy to be extremely distressing.

The family consider this to have been a turning point in Emma’s care and treatment and triggered a fatal downward spiral in her mental health. The jury also heard that Emma reported to staff that she was hearing voices telling her to end her life. 

On the following three consecutive evenings (15, 16 and 17 April 2021) Emma was discovered with ligatures around her neck at around the same time each evening, each of which required staff to use ligature cutters.

On 15 April, her observations were increased from 30 minute intervals to 15 minute “intermittent” observations. On the following day, 16 April, after two ligature incidents in two days, Cygnet’s Daily Risk Assessment, a risk management computer algorithm, raised Emma’s risk level from “green” (low risk) to “red” (high risk). Despite this, numerous members of staff told the inquest that they had not been made aware of these incidents or of an increase in Emma’s risk of harm.

On 19 April, a multi-disciplinary team meeting was convened to discuss whether Emma’s trauma therapy should continue. The jury heard that, despite the clear escalation in Emma’s risk of harm, as evidenced by the life-threatening ligature incidents, and her suicidal ideation and distress caused by the imaginal exposure phase of her trauma therapy, Cygnet staff decided to continue with the treatment and not increase observation levels. 

On 16 April 2021 Emma was given “anti-ligature” clothing and her own clothing was removed for her safety. The inquest was told that, immediately after Emma’s death, Cygnet’s observation policy changed to require that any patient given this clothing must also be on 1:1 constant observation for that period.

Between 19 and 20 April, the jury heard that Emma told six different members of staff that she was either suicidal, wanted to die, was feeling very low in mood or having strong urges to self-harm.

On 20 April, whilst still on 15-minute intermittent observations, Emma tied the fatal ligature, which involved use of the “anti-ligature” clothing. The jury heard that despite Cygnet policy requiring that intermittent observations must be completed within 15 minutes of each other, Emma was discovered 17 minutes after the final observation.

The witness conducting the observations initially told the police that they attended 17 minutes after the final observation. The family understands this was corroborated by CCTV and documented in Emma’s notes. However, the witness told the inquest jury that they actually attended within 15 minutes.

Cygnet’s own Root Cause Analysis report, an internal investigation into the death, found that there were multiple opportunities to reassess risk in the week leading to Emma’s death. They also found that despite a clear escalation in the frequency and severity of life-threatening self-harm that week, she was not placed on 1:1 constant observations. If she had been, the report found it to be likely that she would not have died on 20 April 2021.

CONCLUSIONS

The inquest jury concluded that:

• Despite Emma’s documented and well known incidents of serious self-harm and suicide attempts in the days leading to her death, she was not placed on 1:1 observations which could have prevented her death at the time.
• Due to insufficient level of observations and a misjudgement of Emma’s actual risk, she had the opportunity to [use the] anti ligature clothing to take her life.
• It is clear from a schedule of the CCTV footage that there was a failure to adhere to the policy regarding observation within a 15 minute window.

The coroner is considering whether to issue Prevention of Future Deaths Reports regarding risk assessment and information sharing at Cygnet Hospital, and about the lack of national standards in relation to the manufacture of anti-ligature clothing in the UK.

Caroline Sharp, Emma’s mother said on behalf of the family: “Words cannot do Emma justice: she was a ray of light through her own darkness to her family and friends, and other people’s problems would always come before her own. She was the most loyal person you could meet and treated everyone with respect and as equals. Her smile made you smile too, and her laugh was infectious.

When Emma was transferred to Cygnet Maidstone on 23 July 2020, I thought that she would receive Rolls Royce care, the best money could offer. I hoped it would be a turning point in Emma’s life. Instead, Emma was utterly failed by Cygnet.

The jury’s damning findings vindicate the concerns about Emma’s care that we have had all along. She was struggling to cope with the trauma therapy she was being given, and her cries for help – which were getting increasingly desperate – were ignored. It is a tragedy to know that her death was preventable.” 

Tara Mulcair of Birnberg Pierce solicitors, who represent the family, said: “It is regrettable, and has been deeply distressing to my clients, that senior Cygnet staff who gave evidence at Emma’s inquest failed to accept the findings of Cygnet’s own Root Cause Analysis report, which found that despite the escalating frequency and severity of her self-harming behaviour in the week before Emma’s death, she was not placed on 1:1 observations.

Instead, the jury heard from multiple witnesses that a patient tying a ligature (which can cause death in 1-2 minutes) is not considered to be a ‘serious incident’ in Cygnet hospitals. The jury have rightly concluded that this issue contributed to Emma’s death.”

 Lucy McKay, spokesperson for INQUEST, said: “Emma was trying hard to survive in the face of significant trauma, with the support of her loving family. Yet her mental health was left to escalate to crisis point. 

During her treatment in this private Cygnet hospital, which is supposedly a specialist in supporting people diagnosed with personality disorders, she was clearly struggling. It is abundantly evident that, like too many women dealing with trauma, she was failed.

Society must do more to respond to trauma and support survivors of sexual assault long before their health reaches crisis point. Mental healthcare providers nationally should reflect on the evidence of this inquest, including the dangerous use of ‘anti-ligature’ clothing in place of adequate risk assessment and observation.”

ENDS

NOTES TO EDITORS

For further information please contact Lucy McKay on [email protected]

A photo of Emma is available here.

Emma’s family are represented by INQUEST Lawyers Group members Tara Mulcair of Birnberg Pierce and Tom Stoate of Doughty Street Chambers.

Other Interested persons represented are Cygnet Health Care, Sussex Partnership NHS Trust and Interweave Ltd (the company who manufactures the ‘anti-ligature’ clothing).

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