11th March 2016


A jury has delivered critical conclusions regarding the death of Hannah Evans who was a detained patient on Sheridan Ward, Hollins Park, Warrington at the time of her death.     

Prior to her death, Hannah – a gifted young woman of 22 years – spent over 3 months as a detained patient first at the Weaver Ward in Halton and then at  a psychiatric intensive care unit at Leigh Infirmary.  On 12 January 2015 Hannah was transferred to the Sheridan Ward and within a day – she was dead. 

Despite awareness that Hannah was a complex patient with an extensive history of tying life-threatening ligatures and an intense fear of change, she was given just 2.5 hours notice of her transfer that day. A process described by an independent expert as “abrupt”. 

There was no increase in Hannah’s observation levels during this risky transition phase and indeed, as the jury have found even the basic 4 hourly checks were not maintained.  On the night of 13 January 2015 Hannah should have been checked at 10:45 pm but the jury heard that a search was begun only when Hannah failed to attend for her medications. The jury have found that Hannah was last checked at 10.30 and not found until 10.55 within the accessible toilet on the ward having tied a ligature around an “obvious” ligature point.

It remains a mystery how Hannah managed to access the toilet which should have been locked off at all times and a mystery as to how Hannah came to have this ligature. The inquest learned that the accessible toilet door was often found unlocked, that patients other than those who were disabled used it and that it has since been decommissioned. The Jury also found that Hannah was not searched on her arrival at the Sheridan Ward despite the documented history of her tendency to secrete ligatures and not even asked if she had ligatures about her person.  Although the specific tendency of Hannah to tie ligatures in bathrooms was known such steps as were taken to prevent this occurring on Sheridan were fatally inadequate. 

Hannah’s parents endeavoured to participate in her care and had successfully cared for her in the community – often operating their own 24-watch and searches to keep her safe.  When the fatal decision was made to transfer Hannah off the intensive care unit was discussed they did not object – unaware that Hannah had been involved in 9 ligature attempts whilst on the intensive care unit. Had they been aware of that history they would have objected and in particular blocked her transfer to Sheridan Ward where Hannah had experienced a lack of care in the course of previous admissions.

The Jury found that Hannah died as a result of an accident and made a number of criticisms of the NHS Trust responsible for both the intensive care unit and Sheridan Ward including;
• The proposed comprehensive detailed plan for her care not being executed as intended and new location for her care was limited, lacking in options and alternative care facilities inadequately researched;
• lack of understanding of available electronic communication system (Datix, Otter) leading to insufficient information sharing;
• Failure to adequately assess observation levels for the initial transfer period, knowing incidents had occurred and knowing Hannah’s complex history;
• Transfer process lacking and rushed which meant Hannah’s named care team were not available thus adding to her anxiety levels;
• During the transfer the search process was insufficiently carried out and opportunities were missed to ascertain whether Hannah had secreted items to maintain her safety;
• Failure to properly observe gave Hannah a 25 minute window of opportunity and the means to ligature in the disabled toilet;
• Failure to ensure that ward procedure was followed, and to lock all doors;
• A severe lack of communication between the ward staff and management structure, to highlight day to day issues, led to complacency; and
• A failure to have in place regular checks on ligature points placed patients at risk.

The coroner has agreed to add the entirety of the jury's conclusions to the NHS Trust and NHS England within a Prevention of Future Death’s Report.

Hannah’s family said:

“Hannah was a beautiful, compassionate and intelligent young lady who repeatedly asked for help over a period of ten years. We are devastated that she has died in the very place she was meant to be safest. Our suffering has been made worse by the knowledge that her death could have been avoided if the Trust had not made so many basic mistakes in caring for her.

We feel vindicated by the Jury’s careful and detailed criticisms within their conclusion.

We will be vigilant to ensure the Trust now makes the necessary changes to ensure that vulnerable patients are safe in its care.

We would like to thank our legal team for the work undertaken on the family's behalf.”

Gemma Vine, solicitor representing Hannah’s family said:

“This is yet another very sad case involving the death of a highly vulnerable young woman in an adult mental health unit which could and should have been avoided. This case highlights not only the failings by staff on the Sheridan Ward to protect Hannah, but also a national problem regarding the lack of provisions in place to properly support vulnerable young women, who are diagnosed with Personality Disorders’ and more wider for the large population of this country who suffer from mental health conditions.

Her death is a shocking reminder that there needs to be an urgent improvement in the care of young people by mental health services”

Selen Cavcav, INQUEST caseworker said:

“Hannah was a vulnerable young woman who had a loving family behind her who tried their very best to make sure that she was safe.  It is a real concern that she lost her life in this way in a mental health institution with staff who were supposed to be experienced and trained to deal with her risk of suicide.  The findings of this inquest should act as an urgent reminder to the government to make sure that services and practices in relation to mental health support for young people are improved to such a level that we don’t have another inquest conclusion highlighting basic failures in communication and risk assessment contributing to the death of another  young person like Hannah. 

INQUEST has been working with the family since February 2015.  The family is represented by INQUEST Lawyers Group members Gemma Vine from Lester Morrill solicitors and Fiona Murphy, Doughty Street Chambers