7 March 2022

Before HM Coroner Catherine Wood and a jury
Kent and Medway Coroner’s Court (or remote access*)
Opens Thursday 10 March
Scheduled for seven days

Emma Pring was 29 when she died after ligaturing whilst an inpatient at the privately run Cygnet Hospital Maidstone on 20 April 2021. Emma had been under the care of Sussex Partnership NHS Trust since 2016, and was an NHS funded inpatient at the Cygnet hospital for almost eight months before her death.

Emma was a survivor of rape and was receiving trauma therapy at the hospital, which she found extremely difficult. At the time of her death she was seen as such a risk to herself that she was put in ‘anti-ligature clothing’. However, she used this clothing to make a ligature and subsequently died.

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 two separate incidents of rape when she was 18 and 19.

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.

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 treatment to address the trauma she had experienced.

Emma was receiving trauma therapy, which included exposure techniques facing traumatic incidents directly. She told her family she found this incredibly difficult to cope with.

In the days before Emma’s death there were multiple self-harm and ligature incidents, though her family were not informed of this decline in her health. Emma was subsequently put in ‘anti-ligature clothing’ and her personal items were removed. She said she found this unsettling and humiliating. Due to her risk level Emma was meant to be observed by staff every 15 minutes.

On 20 April 2021, staff found Emma unresponsive with a ligature. She could not be revived. Her family believe this was a cry for help, as Emma had been planning for the future. They hope the inquest will explore:

• The appropriateness, quality and timeliness of the observations, including whether Emma ought to have been on constant 1:1 observations at the time of her death.
• The risk assessments and response to other ligature attempts in the days before her death.
• The appropriateness of the exposure based trauma therapy for Emma and its impact on her health.
• The adequacy of the ‘anti-ligature’ clothing, and risk assessment of it by the hospital.
• The staffing level and experience of staff on the ward, including their knowledge of Emma’s needs.

 The family are also concerned about the way in which the hospital communicated Emma’s death to them. They were only informed by police the morning after Emma had died, and not told anything by the hospital themselves. The hospital said this was their policy.

ENDS

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

*Journalist should contact the coroner’s court to request remote access, via Microsoft Teams. Or media can attend Kent and Medway Coroner’s Court, being heard at Shepway Centre, Oxford Road, Maidstone Kent; Postcode, ME15 8AW.

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

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.