27 January 2023

This is a media release by Bhatt Murphy solicitors, reshared by INQUEST

Before Assistant Coroner Fiona Butler
Leicester City & South Leicestershire Coroner's Court
16 – 27 January 2023

PLEASE NOTE: This document contains details of serious mental ill health, self-harm, and self-inflicted death.

Samantha Boazman died on 22 October 2021 whilst detained under the Mental Health Act at Sturdee Community Hospital, a hospital run by Inmind Healthcare Group.  Her placement at privately-run Sturdee was funded by the NHS.

The inquest into Samantha’s death has now concluded that she died following gross neglect due to a continuous sequence of shortcomings in her care. Their findings included:

  1. That there weren’t effective systems in place to keep Samantha safe on 22 October 2021
  2. That there was a lack of adequate training of staff
  3. That there was a failure to remove ligature risks from bedrooms
  4. That Samantha’s risk was not appropriately assessed or managed
  5. That Samantha was not appropriately observed.

Samantha’s family describe her as a kind hearted, caring, and generous person who would always put others before herself and who knew how to make others laugh. She was intelligent and quick-witted and showed amazing courage in the face of her long standing mental ill health.

Samantha had been admitted to Sturdee Hospital in June 2020 following a breakdown in her community placement. She had a long-standing history of self-harm and the inquest heard evidence that there had been daily incidents of such self-harm in the early part of her admission. By spring of 2021, however, Samantha’s presentation had improved and staff at the hospital began liaising with community mental health services to identify an appropriate placement for discharge.

Although discharge was a known trigger for Samantha, the jury heard evidence that no plans were made to manage that increased risk. In the month before her death, on 17 September 2021 Samantha committed a further act of significant self-harm. As a result, a decision was made to remove specific risk items from her room. That decision was recorded in a risk assessment, which was reviewed on a daily basis by a multi-disciplinary team and displayed in the ward office. The instruction remained in place until her death. However, the inquest heard evidence that no steps were in fact taken to remove such items from Samantha’s room and there was no record of any attempt to do so.

The inquest heard evidence that in the days prior to her death, Samantha’s mental state had deteriorated. She had been seeking increased reassurance from staff (one-to-one’s), spoke of missing her family, she was observed pacing and crying in the corridor and she was noted to be anxious on a number of occasions. These were all recognised indicators of Sam’s escalating risk. On the day before her death, Samantha appears to have been told that she would be moving to another part of the hospital, as a step towards discharge.

On 22 October 2021, Samantha asked for one-to-one’s from a number of staff but it was said that these could not be facilitated due to staffing issues. This was despite this being a recognised mechanism to decrease Samantha’s risk. She also asked for medication to help her feel less anxious but this was not facilitated. She was observed at points to be crying and pacing. A healthcare assistant was sufficiently concerned about Samantha’s presentation that day that she locked Samantha’s bedroom door to ensure that Samantha remained in communal areas. However, after consulting with the ward psychologist, the healthcare assistant was instructed to unlock the door, despite Samantha not having been directly assessed by either the nurse in charge or the psychologist. Instead, Samantha was allowed back into her room and told to practice relaxation techniques. The evidence was that no one reviewed Samantha’s observation levels or undertook a check of her room to ensure that she did not have access to items with which she could harm herself.

Samantha was due to be checked every hour by staff. However, no check was undertaken between approximately 5.30pm and 6.45pm when Samantha was found unconscious, having self-harmed with a specific risk item that remained in her room. The inquest heard that there were delays in staff locating the relevant emergency equipment and in calling an ambulance. Sadly, Samantha died later that day.

The inquest jury heard evidence over 7 days, including in respect of concerns that had been raised both with and by senior managers about the safety and culture of the hospital. Although reliance on agency staff was high, agency staff on the ward on 22 October told the inquest that they had not received an induction from Sturdee Hospital.  

Following Samantha’s death, the Care Quality Commission carried out an unannounced inspection of Sturdee Community Hospital. The Commission rated the hospital inadequate, and found not only that the hospital’s ligature risk assessment was incomplete but that there was also no specific mitigation for ligature risks.

Samantha’s daughter, Chantelle Blood said: "My family has been completely devastated by what has happened to my mum. We thought that she was being cared for and was safe but it turns out that the opposite is true. I know in my heart that my mum had no intention to end her life that day, and the fact that she was allowed to shows how badly she was failed. Her death was completely preventable and I am glad that the jury recognised this."

Charlotte Haworth Hird, solicitor for the family said:"Samantha was seriously let down by the services set up to protect her. As a private provider, Inmind Healthcare was receiving public funds to care for Samantha and keep her safe yet they failed to do so. The seriousness of those failures is reflected in the jury’s finding of gross neglect. The family have heard days of harrowing evidence about how Sam was failed. They were shocked to learn that serious concerns had been raised by a former member of staff about the treatment of patients by senior members of the clinical team and are troubled that those concerns were considered an employment issue rather than a safeguarding one which required investigation and action to protect patients.

This is another shocking case which shines light onto systemic and devastating gaps in the provision of inpatient mental health care. It demonstrates the need not just for an inquiry into the state of mental health settings across the country, but for one which has the necessary powers to fully and fearlessly examine why patients like Samantha, and their families, continue to be failed."

Selen Cavcav, senior caseworker at INQUEST said: “This inquest finding should shame  ‘Inmind Health Group’ and also the commissioners who deemed it safe for the care of  vulnerable individuals.   

No family should have to witness their loved ones dying in this way and hear evidence of neglect and total incompetence by people entrusted with their care.

The time to take decisive action is long overdue. Outsourcing of mental health to private providers which lack visibility and systems of accountability is dangerous and costs lives.”


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

For further information or request for comment please contact Charlotte Haworth Hird at Bhatt Murphy on 020 7729 1115 or [email protected].

Chantelle Blood is represented by INQUEST Lawyers Group members Charlotte Haworth Hird and Amy Ooi of Bhatt Murphy and Frederick Powell of Doughty Street Chambers.