25 November 2019

Before HM Assistant Coroner Sean Horstead
Brighton and Hove Coroner’s Court
11 November – 22 November 2019

The inquest into the death of 26 year old Bethany Tenquist, known to her family as Beth, has concluded with the jury finding a sequence of serious failures relating to staffing, leadership and safeguarding processes on the Caburn Ward probably had a direct causal connection to her death.

On 29 December 2018, Beth was found unconscious with self-inflicted injuries in her room at Mill View Hospital in Hove, a mental health hospital run by Sussex Partnership NHS Trust. She died two and a half weeks later on 16 January 2019 at Royal Sussex Hospital, from brain injury as a result of hanging.

The inquest jury found the following issues probably contributed to Beth’s death:

  • the lack of an overarching, dynamic and patient centred care plan led to failures to assess, treat and safeguard Beth appropriately;
  • the lack of safety plans to address the stockpiling of prescription drugs, access to alcohol and allegations of bullying by another patient;
  • a series of failures in relation to risk management, including administrating medication while intoxicated and inadequate observation levels;
  • the nature and extent of staff deployment on Caburn Ward on 29 Dec 2018 was inadequate and led to failures;
  • a failure to adequately search Beth’s room and failure to identify the ligature which Beth used;
  • the level of Beth’s risk of self-harm and suicide was not appropriately assessed or managed by staff;
  • a failure by staff at Mill View to make one or more safeguarding referrals.

The inquest heard that Beth had diagnoses of emotionally unstable personality disorder, bulimia and post-traumatic stress disorder. She developed serious suicidal ideation and from September 2017 had numerous involuntary inpatient admissions arising from her serious risk of self-harm. Her final admission to the Caburn Ward was on 18 September 2018.

Evidence was heard that Beth would regularly use alcohol as a coping mechanism and this increased her risk of self-harm. Despite alcohol being prohibited on the ward, Beth would appear intoxicated on a regular basis. It was understood that Beth was being provided with alcohol through other patients on and would obtain it when she absconded. Despite this, the jury heard that Beth would not be checked on re-entry to the ward.

There were also instances of patients stockpiling medication on the ward and at least on one occasion a blood test showed Beth had consumed medication she was not prescribed. The inquest heard that there was a reliance on temporary staff which meant searches to remove dangerous objects, alcohol or stockpiled medication were not completed daily as they should. The clinical nurse lead said this was also as a result of a ‘lack of leadership’ and a lack of governance around systems and processes at the hospital, which the jury repeated in their conclusions.

During this admission on the Caburn Ward, Beth reported bullying by other inpatients as well as a physical assault. There were also concerns regarding a sexual relationship with another patient which was potentially abusive and exploitative although no formal safeguarding referral was raised in relation to this, which the jury found to be a failure.

The day prior to Beth’s death, there was an incident of bullying by another patient. On the afternoon of the 29 December 2018, Beth was distressed and agitated by this incident. She sought to raise this with a member staff but according to her mother Bernadette, staff said Beth was ‘emotional’ because she had had a drink. After being dismissed by staff, Beth reported the bullying to Sussex Police who told Bernadette they would call her again the following day to follow up the complaint.

Later that evening, Beth declined to take a breathalyser before she took her medication. Despite this, a member of staff who was new to the ward administered the medication, which was against Beth’s care plan. A fellow patient later reported that she saw Beth swallowing a handful of additional pills and evidence was heard that she had been ‘staggering’ down the corridor. Concerns were raised by the patient about her wellbeing, but staff responded that Beth had only taken her normal medication and needed to sleep it off.

An observation log suggested that Beth was seen by a health care assistant at 11.02pm. Evidence was heard that 15 minutes later, the same health care assistant tried to open her door before becoming aware Beth had ligatured, although this timeline is not accepted by all the staff. Despite Beth appearing unconscious and in immediate need of medical attention, the ambulance was not called until 11.31pm. Witnesses from the ambulance service told the inquest that the sooner the basic life support is started, the greater the chance of survival and in this case, if staff had got to her ‘minutes’ earlier, ‘this would have made a difference’.

A safeguarding referral was submitted by Paramedics attending the scene who expressed serious concern about an intoxicated patient being left alone – according to staff that they spoke to on Caburn Ward that night - ‘for 10 minutes’.

The coroner indicated that he will be making a report to prevent future deaths in relation to concerns that there remains an insufficiently rigorous policy for searching visitors and patients on entry onto the ward.

Beth’s siblings said:There is an overarching feeling of sadness. Ultimately, we feel that there has been a failure of the system. The more you think about it, the more you realise that this is what 10 years of austerity does. Why was an NHS hospital relying on bank staff, with zero hour contracts, to care for such complex patients?

Mum has done everything for Beth, not just throughout her life - looking after her 24/7. Since Beth died, mum’s entire year has been focused on compiling information for this inquest. She’s been unstoppable, no matter what we said, because she wanted to see justice for Beth.”

Selen Cavcav, Senior Caseworker at INQUEST said: “Caburn Ward was not a place of safety for Beth. It was a ward in crisis with a dangerous culture. Inexperienced staff, unregulated access to dangerous items and unchecked bullying and exploitation. Beth was failed by the services which should have protected her.

Part of the reason families go through this painful process is to ensure that no one has to live through the same experience. However, this is not the first time these same failings have contributed to a death on this same unit. Enough is enough. There is an urgent need to create an independent national oversight body to monitor action taken in response to recommendations from inquests. This is vital in order to prevent future deaths.”

Basmah Sahib of Bindmans, who is representing the family said: “We are extremely grateful to the jury for their diligent attention to the evidence in this case. Although the jury’s findings are in tandem with the candid admissions of the NHS Trust’s witnesses, it is very difficult and sad to hear that Bethany’s death was preventable. We hope that the NHS Trust will address these systemic issues so that the lives of the women on Caburn Ward are protected in future."



For more information contact the INQUEST Communications Team on 020 7263 1111 or Lucy McKay and Sarah Uncles on [email protected] and [email protected]

INQUEST has been working with the family of Bethany Tenquist since March 2019.  The family is represented by INQUEST Lawyers Group member Basmah Sahib of Bindmans Solicitors and Allison Munroe from Garden Court Chambers.

The other Interested Person represented at the inquest is Sussex Partnership NHS Foundation Trust.

At a pre-inquest review hearing on 20 March 2019, HM Senior Coroner Veronica Hamilton-Deely, who opened Beth’s inquest, was so concerned about the care of patients at Mill View Hospital that she wrote a report to prevent future deaths before hearing any live evidence. The report expressed a series of concerns including that vulnerable patients were continuing to self harm and that checks and the removal of items considered dangerous to patients were incomplete and flawed.

Other deaths at Mill View Hospital

There were four self-inflicted deaths at Mill View in 2011. An investigation into the hospital found that junior and inexperienced staff were supporting the most complex and acutely ill patients.

  • Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care, including incomplete, insufficient and at times contradictory nursing records, handovers, risk assessment and care plan and a failure by hospital administration to provide sufficient staff. Media release.

The coroner issued a report to prevent future deaths in July 2017, requiring that the inadequate staffing levels were addressed.

We are also aware of a number of other deaths relating to the same ward, as reported in local press.

Other deaths under the care of Sussex Partnership NHS Foundation Trust

  • Sabrina Walsh, 32, died on the Woodlands Ward in 2016. The jury found gross failures and neglect contributed to her death. Media release, July 2017.