Evangeline Wilson inquest concludes: Family say her death was avoidable

8 March 2024

Before HM Area Coroner Dr Peter Harrowing
Avon Coroner’s Court, Ashton Court Mansion, Long Ashton, Bristol, BS41 9JN

Heard 19 – 23 February, concluded 8 March

Evangeline Wilson, 24, known to her friends and family as Evie, died a self-inflicted death on 10 July 2022 at her home in Bristol whilst on a ‘short period’ of leave from Cassel Hospital, which is run by West London NHS trust (WLT). An inquest has found that Evie died as a result of morphine toxicity but that her intent was unknown.

Born in Bristol, Evie was a joyful, mischievous and exuberant child. A talented artist, she had accepted a place to study fine art at a prestigious art school in London.

Evie had a complex history of mental health problems including bulimia, depression, severe self-harm, suicide attempts and post-traumatic stress disorder. She was under the joint care of the hospital and Avon and Wiltshire Mental Health Partnership NHS Trust (AWP).

In 2022, Evie’s mental health team arranged a referral for residential treatment. Evie spent the first half of 2022 preparing herself for her admission, she demonstrated increasing distress but neither AWP or WLT re-considered the viability and safety of the planned admission. A key CPA meeting on 6th June organised by the Bristol team did not involve either the London team or the family. There were repercussions from this omission. On 22 June that year, she was admitted to the Cassel Hospital, London, as an informal inpatient.

Evie then began to exhibit increasing distress. Her allocated Cassel Hospital named nurse said that she did not have any 1:1 primary nurse time with Evie due to the fact she went off sick with covid and no other care plans were made in her absence. Several indicators in her care plan showed she was at high risk of self-harm. The Cassel Hospital’s risk assessment of Evie differed from that which AWP had previously formulated and contained less information, particularly in the regard to Evie’s coping mechanisms. Evie then exhibited physical symptoms and on 2 July she had a seizure and five days later developed a fever. The records do not indicate that any medical investigation was undertaken by WLT.

Despite this, on 8 July, Evie was sent home to Bristol on a period of ‘short leave’ due to staff discovering that Evie had consumed alcohol to manage her distress. There was no apparent consideration of the fact that the use of alcohol was one of the relapse indicators in Evie’s AWP safety plan. As this broke the Cassel Hospital behaviour contract, Evie was asked to return home for four days. The coroner heard this was to ‘protect the treatment’ and ‘maintain boundaries’ that Cassel Hospital provided. After the decision was made it transpired that Evie had self-harmed and had wounds on her leg, two of which were long and deep. No arrangements were made for her wounds to be assessed by a nurse. Self-harm was another coping mechanism for Evie and another indicator of relapse.

The coroner heard that Evie was to return to the Cassel Hospital on 12 July for a meeting. Her train was booked and she was sent home, alone. Nursing notes document how she was escorted off the premises. The coroner heard that Cassel Hospital staff had decided not to contact Evie themselves during the period of ‘short leave’ so she could have some time to think. It was, however, revealed in evidence at the inquest that WLT’s own policy was that “[t]here should be a plan for contact with the patient during the period of short leave”, decided in a management meeting or MDT staff meeting.

An email was sent to AWP’s community mental health team indicating that Evie was returning home. This was a unilateral decision with no attempt made for a shared decision making with Evie’s home team, who knew her well. Evie’s Consultant at AWP told the coroner that his knowledge of Evie led him to draft the plan he did. He set out a safety plan for that weekend:

Duty team to contact Evie by telephone on the Saturday and Sunday
Crisis Team to be made aware that she had been sent home
The Psychiatric Liaison Team to be made aware in case she presented at A&E
A follow up on 11 July to discuss Evie’s care and arrange for her Care Coordinator to contact her.

No-one checked if her social support was available that weekend, including her family. The coroner heard that this was the only contact the Cassel had with AWP the whole time Evie was there, in their policy there was supposed to be contact every week.

Two days later, on 10 July, Evie was found dead in her flat. No one from the duty team contacted Evie over that weekend. The duty team nurse on the Saturday was on sick leave, no one else was told to make the call. On the Sunday, the call was not made either, the reason was unknown. The coroner heard that AWP did not have any formal mechanism for safety calls to be made at weekends, and that such requests sometimes led to these calls being made, and sometimes they were not. Evie’s mum called the crisis team requesting a welfare check for Evie, two nurses went to her flat, they shouted out to Evie, the door was locked, the nurses called the police, and they went to Evie’s flat.

The coroner concluded that Evie died as a result of morphine toxicity. He felt that he was unable to conclude as to what her intention was. He did make a finding of fact that the welfare checks which were requested over the weekend of 9/10 July were not conducted for reasons that were not properly explored by the court.

Dr Nick Wilson, Evie’s father, said:

“We wholeheartedly believe that Evie’s death was entirely avoidable. Her family and friends are left wondering how this could have been allowed to happen.

The annual report on UK deaths of in-patient psychiatry patients tells us that half of these deaths occur when patients are on agreed leave and that day 3 of leave is the day of highest risk. Avon and Wiltshire Mental Health Trust NHS Trust (AWP) were supposed to call her over that weekend on both her 2nd and 3rd day of leave. These phone calls never happened. There was therefore nothing in place to protect her from that risk over that weekend. Her in-patient unit, Cassel Hospital part of West London NHS Trust, chose not to offer any support whatsoever over that weekend.

There is an enormous amount of information that has been made available to us, only now because Evie is dead. Our faith in a professional, caring and effective healthcare system has been shattered and we both speak as people who have worked for the NHS. I continue to work for the NHS as a GP. There is much more to be said in another forum.”

See below for full quote.

Selen Cavcav, Senior Caseworker at INQUEST, said:

“Inquest after inquest we see similar failures around shambolic early intervention processes and punitive rather than therapeutic settings, which are unable to keep vulnerable patients safe.

The coroner in this case refused to criticise the trust, foreclosing the possibility of learning or accountability, and failed to make a single recommendation to prevent future deaths.

Evie's family and other bereaved families whose lives have been shattered as a result of these failings deserve more. We are incredibly disappointed by these conclusions.”

Gemma Vine, at Ison Harrison solicitors, said:

“This conclusion comes only one week after this Coroner concluded another inquest into the death of another young vulnerable woman Maia Schroder-Lewis where yet again he has returned a non critical conclusion in a case involving AWP.

Although the Coroner was obliged to record that the welfare checks over the weekend of the 9/10 July had not taken place as per her plan for that weekend, he refused to even consider that this may have been causative or at the very least a missed opportunity in preventing Evie’s death. Had he had proper consideration of Evie’s past history with services he would have seen a pattern of her being open when she was in crisis. The opportunity though for her to able to do this, in this case was missed due to the failure of AWP in making those calls.

From a learning lessons point of view it is of great concern that in the original version of the mortality review prepared by AWP there was no mention of the fact that these welfare checks were not conducted only that a safety plan had been put in place and that this demonstrated good practice on behalf of AWP. It took for the failed calls being referenced in Evie’s Care Coordinators witness statement to the coroner for the family to be made aware that AWP had not complied with their own safety plan for that weekend. This is concerning when the main purpose of the mortality reviews and internal investigations report is to ensure that where failings have happened, lessons are learned so that the failings do not happen again.”

ENDS

NOTES TO EDITORS

For further information, please contact Leila Hagmann on [email protected].

The family is represented by INQUEST Lawyers Group members Gemma Vine and Cara Wiltshire of Ison Harrison and Paul Clark of Garden Court Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.

Other Interested persons represented are West London NHS Trust and Avon and Wiltshire Mental Health Partnership NHS Trust.

Other relevant cases

Maia Schroder-Lewis, 21, died on 1 September 2022 whilst on vacation during the summer vacation between her second and third years when she was living at home in Bristol. Maia’s mental health declined when she started university and was exacerbated by the pandemic. She had been denied access to AWP Crisis Team mental health support through a Bristol helpline because as a student she was registered to a GP in Cardiff. The family was dissapointed and frustrated by the uncritical inquest. Media release.
Jess Durdy, 20, died on 16 October 2020 whilst at Link House crisis house in Bristol, having only moved in five days before. She had suicidal thoughts but was sent to a crisis house with untrained staff, rather than a formal mental health setting. Her family have spoken out about their frustration at the uncritical inquest into her self-inflicted death. Media release.
Zoe Wilson, 22, died a self-inflicted death whilst a voluntary patient at a Bristol mental health hospital on 19 June 2019. An inquest found that multiple failings by AWP contributed to her death. Media release.
Alexandra Greenway, a 23 trans woman from Bristol, died a self-inflicted death on 11 May 2019. Just over a month before her death, she had been detained under section by police following a suicide attempt. The coroner did not draw conclusions on the quality of care Alexandra received from her GP or mental health professionals at AWP. Her family spoke about their frustration at the uncritical inquest. Media release.
Luke Naish, 28, died in hospital on 2 October 2018, three days after he was found ligatured. Luke had both psychosis and substance misuse issues and was under the care of AWP community mental health services in Bristol. His parents remain concerned about the uncritical inquest and the care Luke received prior to his death. Media release.
Becky Romero, 15, died in July 2017 shortly after being discharged from a mental health hospital in Dorset. The coroner found that her death was accidental and contributed to by neglect of AWP and Dorset HealthCare NHS. Media coverage.

Full quote from Dr Nick Wilson:

"We wholeheartedly believe that Evie’s death was entirely avoidable. Her family and friends are left wondering how this could have been allowed to happen.

The annual report2 on UK deaths of in-patient psychiatry patients tells us that half of these deaths occur when patients are on agreed leave and that day 3 of leave is the day of highest risk.

Evie was last spoken to by her grandparents at 9pm on the evening of the second day of her leave and it is likely that she died at some point the following day. The only safety mechanism which was put in place for her leave was that the duty team from her home mental health trust, Avon and Wiltshire Mental Health Trust NHS Trust (AWP) were supposed to call her over that weekend on both her 2nd and 3rd day of leave. These phone calls never happened. There was therefore nothing in place to protect her from that risk over that weekend. Her in-patient unit, Cassel Hospital part of West London NHS Trust chose not to offer any support whatsoever over that weekend.

After Evie’s death, AWP conducted an internal routine ‘mortality review’ rather than a significant incident review. The first draft took 10 months to arrive. That draft implied that a safety plan was put in place over that weekend and therefore the service provided was good. However, what the report did not state was that the plan was never followed and those phone calls that were supposed to be made over that weekend never happened.

It was only through the witness statement from her care coordinator provided in the coroner’s disclosure bundle did it come to light that the plan was never followed. Only then did AWP amend their report to include those failings. As a family this is really concerning as how can you ever trust AWP to tell you the truth if they have just demonstrated to us that they tried conceal from us that, the safety plan wasn’t followed. Furthermore, knowing that the contact Evie had at that weekend was a crucial part to the inquest they then attended the inquest having not investigated what process was put in place, how it was put in place, who was responsible for making those calls and how it came about that the calls were not made. This to us does not demonstrate a trust learning lessons from this death.

The report also congratulated AWP on providing a triangle of care including contact with the family stating that there were monthly planned meetings with us about Evie’s care when in reality we had no contact whatsoever with AWP for the last 9 months of Evie’s life.

The only acknowledgement from AWP in their review about failings in Evie’s care related to a failure to include key people like Cassel Hospital at Evie’s last CPA meeting on 6 June, only weeks before her planned admission to the Cassel, that a contingency plan was not put in place for her periods of leave from Cassel and no plan of contact between Cassel and AWP whilst she was a patient at the Cassel.

Within the review that was carried out by West London, responsible for the Cassel, they started that response from the staff regarding Evie having a suspected seizure and also her self harm incident was prompt, thorough and sensitive. Unfortunately, I did not hear any evidence at the inquest that satisfied my concerns regarding her care in respect of both incidents and will be considering how I can take my concerns further.

One of the recommendations that came out of the West London investigation was that they should “consider the provision of specialist training in suicide risk assessment and safety planning in recognition that this is one of the most challenging areas of clinical practice’ and ‘setting out a structured/systematic approach for the assessment, planning, implementation and evaluation of safe, high quality care and supporting the development of local protocols that set out local care planning processes including the assessment of risk and need.

It is difficult for us to accept that an NHS level 4 national referral centre for people with mental health problems associated with high risk behaviours did not have in place adequate policies around risk management and up to date suicide prevention training in place. Whatever changes are implemented now, none of them will bring Evie back.

Evie helped write her own safety plan to guide healthcare professionals involved in her care however we feel that this was completely disregarded by the Cassel. The team that assessed Evie’s risk at the Cassel told the coroner they would make the same decisions if faced with the same situation again, which to us demonstrates that no one has come away from this process having learned from her death.