29 June 2022

Before HM Coroner Dr Peter Harrowing
Avon Coroner's Court
20 – 29 June 2022

The family of Jess Durdy, a 27 year old woman from Bristol, have today spoken out about their frustration at the uncritical inquest into her self-inflicted death. She had suicidal thoughts but was sent to a crisis house with untrained staff, rather than a formal mental health setting.

The family are concerned an opportunity to prevent future deaths has been missed by the inquest, which is uncritical despite a critical internal investigation by the mental health provider. The inquest found that on the balance of probabilities Jess took her own life. In a short form conclusion, Bristol and Avon Coroner Dr Peter Harrowing said her death on 16 October 2020 was a suicide.

The coroner did not draw conclusions on the quality of care by mental health professionals at Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) or staff at Link House, a crisis house for women in mental health crisis that Jess was staying in at the time of her death.

The coroner previously rejected the family’s request for a wide-ranging inquest (under Article 2 of the Human Rights Act) which could have considered the broader circumstances. Despite this, Jess’ family was able to persuade the Legal Aid Agency to fund their legal representation on the basis that it was arguable that a systems failure by South Western Ambulance Service Trust contributed to Jess’ death.

Namely, that there appears to be no way to trigger an immediate (category 1) emergency response where a person is at risk of hanging but a third party caller cannot get into the room to check whether they’re breathing.

Background

Jess grew up with her mum Moira, dad Ken, sister Samantha and brother James in North London. She was a bright, sparky and caring child, dearly loved by everyone who knew her. She left home at 18 to go to Bristol University to study civil engineering. She was academically very able and completed her Masters of Engineering in 2015.

Having worked in Bangladesh in an irrigation infrastructure project with the charity Engineers Without Borders, followed by travelling in Asia, Jess returned to Bristol in 2016. It was the city she had grown to love and still had many friends. She worked for the Environment Agency in the South West on a graduate civil engineer training scheme.

Jess died on 16 October 2020 whilst at Link House crisis house in Bristol, having only moved in five days before. She was referred there by the AWP Mental Health Recovery Team because she was struggling with daily suicidal thoughts that were becoming increasingly intense and intrusive.

The court heard evidence over five days from professionals working with Jess. They described her as a private person who found it difficult to build trusting relationships with services. Despite this, there was evidence from Jess’ counsellor that, when asked about her thoughts, Jess would say that if she was going to take her life she would do it by hanging because it was the method that made the most sense to her.

No one at AWP or Link House asked Jess about this and staff at Link House had not been informed by AWP that Jess had previously attempted to hang herself. Had they known, staff said they would have asked Jess if they could have removed the item which she went on to use as a ligature.

Due to a complete lack of clinical oversight at Link House, untrained, unqualified staff who did not know the difference between suicidal thoughts and plans were tasked with caring for Jess and escalating any problems. Even though Jess told staff on three consecutive days that she was having very strong urges of ending her life by strangulation, Link House staff did not see this as a major risk. Instead they attempted to contact the Recovery and Crisis Teams as a matter of ‘good practice’ but did not follow up on these calls when there was no response.

For Jess’ family, Link House was never safe for her. It is supposed to be an alternative to psychiatric inpatient admission but there are no clinically trained or registered staff on site. To make matters worse, nobody at Link House seemed to have properly appreciated that there were obvious ligature points in residents’ rooms.

These included a closing mechanism over lockable doors that ultimately prevented entry by Link House staff to administer emergency first aid and considerably delayed the response of emergency services. This is despite the door closures having been identified as a risk by previous Link House staff.  

These factors meant that there was no chance of Jess surviving on 16 October 2020. It has been tough for Jess’ family to hear witnesses constantly say how ‘positive’ it was that Jess was making disclosures about intrusive thoughts when she was clearly in great distress and asking for help.

The suggestion that Jess’ risk had not escalated to the point where the Mental Health Crisis Team had to be contacted was not consistent with staff calls to the Recovery Team and plan (not actioned) to contact the Crisis Team. In addition, during the call to the emergency services which was heard by the court, staff expressed how concerned they really were. It is unclear how explicit Jess would have needed to be about her plans of suicide for staff to actually offer to help make her safe

An AWP investigation on Jess’ death identified numerous care and service delivery failures, but the coroner did not make any criticism of the deficits in care.

The call to the emergency services was particularly worrying. Link House staff are not trained in making emergency calls and so do not know that the ambulance service relies on buzzwords to trigger a Category 1 (immediate) response. When staff told the ambulance service that they were concerned as Jess had been having very strong urges to take her own life and they were unable to enter her room the call was allocated a Category 3 response for a welfare check.

The ambulance took 30 minutes to arrive. During this time Link House staff were standing at Jess’ door, unable to enter and holding a ligature knife. This apparently could not have been avoided, even if the nature of the emergency had been better communicated, as no one could get in to tell the ambulance if Jess was breathing. This information would have been needed to trigger a Category 1 response.

All of this made Jess’ death entirely preventable and, although some changes have been made – such as the closing mechanisms on doors now being on the outside – it does not seem that any material change has happened in the last 18 months. There is still a need for clinical support on site at Link House.

Given the increasing use of voluntary sector crisis houses across the UK by Mental Health Trusts, there is a real possibility that this frailty in assessing and managing suicide risk by unqualified staff could be replicated elsewhere.

With clinical oversight comes regulation, which is something that had been completely lacking at Link House. Although commissioned by the Clinical Commissioning Group and integrated into AWP services, there is no audit of the premises, independent oversight of procedures in place and no checks to ensure that staff are appropriately qualified and trained to work with vulnerable women like Jess.

Moira, Jess’ Mum said: “Our grief at the loss of Jess is profound and endless. A light has gone from our lives, and we will miss her forever. She tried so hard to get the help she needed, but the Mental Health Services provided by AWP did not function for her.

She had asked sensible questions in order to understand the newly prescribed medication which could have helped. These were not answered, and so the opportunity of pharmacological intervention was lost. Once at Link House, staff from AWP had no further direct contact with her. She was left in the care of the junior support staff who worked there, who had received no recognised training in risk assessment.

Despite desperately informing the support workers on three successive days how frightened she was by her intrusive thoughts of ligature, no meaningful action was taken to assess her risk, keep her safe at Link House or to request professional help from AWP.  As a result of these failures, we have lost the daughter and sister we loved so much.

We are so disappointed that this coroner has decided to return a non-critical conclusion with regards to the clinical oversight by AWP of Jess’ care and the lack of effective risk management once in the crisis house. We are also astonished that he has failed to recognise that placing an internal door closure in the bedroom can be anything but grossly negligent.

We are further disappointed by AWP’s lack of acknowledgement of the things that went wrong, and by their legal representatives continued attempts during the inquest to halt relevant questioning, with a complete lack of regard to the effect this has had on those most devastated by the loss of Jess.”

Ken, Jess’ Dad said: “Sadly Jess hid her illness from those that loved her most and chose to put all her faith in mental health professionals. NHS Mental Health Teams should not be transferring care for those in escalating crisis from the hands of qualified and registered staff to the mercy of the unqualified staff where there are unregulated systems of care in place like at Link House. We still do not think that Link House is a safe place.”

Gemma Vine of Ison Harrison Solicitors, who represented the family, said: “Psychiatrists have been raising the alarm on the national shortage of mental health bed spaces for years but it has only got worse through the pandemic. Voluntary sector crisis houses are increasingly used as an alternative to inpatient care, but whether a patient will get the necessary clinical support throughout their stay is a postcode lottery.

Tragically, Jess was left in a place where staff did not have the requisite training to identify the obvious risk to her life. Even the Trust struggled to understand who retained overall responsibility for Link House despite it having been a commissioned service since 2009. Jess’ family have tirelessly worked to understand and evidence these failings to ensure it does not happen to anyone else in the future. Without proper regulation and oversight, avoidable deaths will continue to happen.”

Jodie Anderson, Senior Caseworker at INQUEST, said: “Jess’ case is a stark reminder of the often impossible struggle young women in the midst of a mental health crisis face in getting their voices heard. From the evidence, Jess could not have been more vocal about her deteriorating mental state and yet staff at Link House did little to raise the alarm.

Crisis Houses are no safe alternative to psychiatric inpatient care. An overreliance on these spaces in lieu of NHS beds puts people at real risk. It is only through the sheer determination of Jess’ family to have her voice heard through the process that the extent of systemic failings was truly exposed in a highly critical Serious Incident Investigation.

We do not believe the inquest conclusion reflect these failings. We see in Jess’ case yet another lost opportunity to prevent future deaths.”

ENDS

NOTES TO EDITORS
For further information, a photo and to note your interest, please contact Lucy McKay on [email protected]

Jess’ family are represented by INQUEST Lawyers Group members Gemma Vine of Ison Harrison Solicitors and Ciara Bartlam of Garden Court North Chambers. They are supported by INQUEST caseworker Jodie Anderson.

Other Interested persons represented are Avon and Wiltshire Mental Health Partnership NHS Trust, Link House, South Western Ambulance Service and Avon and Somerset Constabulary.

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

Other relevant cases:                                                         

• Alexandra Greenway, a 23 year old transgender woman from Bristol, died on 11 May 2019 whilst under the care of AWP. There was evidence of issues around a lack of access to treatment, including following a suicide attempt the month before her death. Despite the evidence, the coroner Dr Peter Harrowing did not make critical findings. See media release, October 2020.
• Luke Naish was 28 years old when he died in hospital on 2 October 2018, three days after he was found hanging. Luke had both psychosis and substance misuse issues and was under the care of community mental health run by AWP. Despite concerning evidence, the coroner Dr Peter Harrowing did not criticise the issues with the care and support prior to his death. See media release, February 2021.
• Oliver McGowan was 18 years old. He had learning disabilities and autism and was in general hospital for seizures when he died due to a combination of pneumonia and hypoxic brain injury in Southmead Hospital, Bristol. The brain injury was caused by an adverse effect of antipsychotic medication, Olanzapine. The coroner, Dr Peter Harrowing, was uncritical despite the evidence and family’s belief that Olanzapine should never have been prescribed. See media release, April 2018.