15 December 2017

Before HM Coroner Jonathan Leach
Wakefield Coroner’s Court
4-14 December

The inquest into the death of Katie Hamilton, 26, concluded yesterday, with the jury finding they did not believe Katie intended to take her own life. She died in hospital, three days after being found unconscious with a ligature whilst a secure mental health inpatient at the Becklin Centre in Leeds on the 9 March. Throughout her life, Katie campaigned and volunteered to support others with mental health difficulties.

The jury heard evidence from mental health professionals involved in Katie’s care, and from Independent Expert Consultant Forensic Psychiatrist, Dr Christopher Green. After over a day of deliberating they returned a conclusion of misadventure. The jury stated that on the 9 March 2016 in the Becklin Centre, Katie deliberately ligatured but did not intend the outcome to be fatal, knowing she was being observed by the hospital every 15 minutes and would be found.

Katie arrived at the Becklin Centre on 9 March in significant distress. She had been admitted following three days in which she had two serious overdoses and made numerous attempts to ligature whilst on the general ward and within ICU of St James Hospital. Katie’s mother gave evidence that she had noticed a significant difference about Katie’s presentation. She said in the past Katie had always expressed a wish to live after attempts at self harm, but on this occasion Katie's sense of despair and hopelessness continued. 

Katie was restrained by police during her transfer from an Intensive Care Unit (ICU), where she was being treated following an overdose. It was accepted during the inquest that this heightened Katie’s levels of distress, and that it was highly unusual for a patient to be transferred straight from the ICU, a mere 6 hours after being removed from ventilation, to a mental health acute ward.

Katie had a long history of self harm and contact with mental health services, with her mental state being exacerbated as she had recently lost a friend to suicide and was worried about possible instability in her housing. The jury heard that prior to Katie's arrival at the Becklin Centre, a decision was made by staff there for her to be on 15 minute observations. The decision was not altered on her arrival, despite her presentation. This was a significant change from the care plan devised by a Consultant Psychiatrist and his colleagues treating Katie whilst she was at St James, who stipulated she should not be left alone at any time due to the risk she posed to herself.

The Independent Expert gave evidence stating that the initial assessment and handover was good practice. However, he said no reasonable practitioner would have come to the view that 15 minute observations were appropriate that evening. Given the immediate background he believed it highly likely that she would engage in self-harm, saying had there been a staff member constantly observing her, they would have been able to intervene, as was the case during her time on the general ward and ICU. He noted this is not only the expert view, but a common sense approach. 

Emma Hamilton, Katie’s mother said:
“To know Katie died in torment not receiving the professional help she needed and deserved is something no family should have to go through. There are many resource issues within mental health services, but there are other very important issues. It is the attitudes, beliefs and training that some health professionals have about people with mental health problems that lead to deaths like Katie’s.

It can no longer be acceptable, or safe, to be diagnosis-led in caring for people like Katie. My daughters NHS care was entirely led by her diagnosis. The assumptions, judgements and discrimination is common for people diagnosed with Emotionally Unstable Personality Disorder. People with this psychiatric label are often felt to be attention- seeking and not deserving of respect and care.

Well I can tell you that my daughter was much, much more than her diagnosis and difficulties. She was intelligent compassionate, wise and loving and I am so very proud to have had her as my daughter for 26 years. It could, and should, have been for much longer"

Deborah Coles, Director of INQUEST said:
“We are increasingly concerned about the repeated patterns of failure in the treatment of vulnerable women like Katie in secure mental health care, the very place they should be safest. It seems plainly obvious that Katie was at extreme risk, and yet clearly those charged with her care were both unable and ill equipped to manage this. We commend the work that Katie’s family and friends are doing to change attitudes, and urge the Department of Health to address these most challenging and urgent issues.”

Gemma Vine, Solicitor for Emma Hamilton said:
“As a Practice, we have seen an increase in the numbers of cases that we have taken on involving deaths of vulnerable men and women in mental health settings. Over the course of this inquest the Coroner and the Jury heard evidence of the limited number of mental health beds not only regionally but nationally and in Katie’s case over the two day period prior to her transfer to the Becklin Centre there was not a single bed on a female ward in the whole of this Country, which is why she remained in St James Hospital for so long. Mental Health Services are clearly in crisis and without urgent and immediate change we will continue to see deaths like Katie’s occur”



For further information and to note your interest, please contact Lucy McKay here.

  • INQUEST has been working with Katie’s family since 2016. The family is represented by INQUEST Lawyers Group member Gemma Vine of Minton Morrill Solicitors and Alan weir of Parklane Plowden Chambers.
  • Details of other critical inquests raising similar issues following the deaths of young women in secure mental health care are detailed in the following recent press releases:
    • Jury finds gross failures and neglect contributed to the death of a vulnerable detained patient in Sussex Partnership NHS Foundation Trust ward (link)
    • Inquest into death of Linsay Bushell identifies multiple failings (link)
    • Inquest jury finds neglect by NHS trust contributed to death of 24-year-old mother from Folkestone (link)
    • Repeated Failures Found By The Jury At The Conclusion Into The Death Of Helen Millard At The Westlands Mental Health Unit (link)