17 November 2020

A review published today by the Warrington Safeguarding Adults Board has concluded that the self-inflicted death of Laura Davis was facilitated by staff at the inpatient mental health facility, Arbury Court.

Laura was 22 years old when she was found unresponsive on her bed on 20 February 2017. On the day of Laura’s death staff granted her unsupervised use of problematic materials, despite what was known to staff about her recent self-harming behaviour, her history and her wellbeing at the time.
Laura was from Brixham in Devon, and grew up in Cheltenham. She enjoyed flying drones, and was a hard-working and high achieving student. She had ambitions of going to Wellbeck college and then on to Sandhurst to become an RAF officer. Her family say she was very caring and intuitive, and she always put others before herself.
Laura had a diagnosis of Emotionally Unstable Personality Disorder. She was admitted to Wotton Lawn mental health hospital in Gloucestershire in June 2016. She was a victim of sexual assault and had a known history of serious self-harm, which continued during her time at Wotton Lawn.
In November 2016, Laura was transferred to a privately run mental health unit called Arbury Court, over 120 miles away in Warrington. Arbury Court is run by Elysium Healthcare but Laura’s placement was funded by the NHS.

This was originally intended as a short-term placement, but Laura remained at Arbury Court for over three months due to delays in finding a more suitable placement for her. Laura died just days before she was due to be transferred to a new placement to receive specialist treatment.
The Safeguarding Board’s investigation has highlighted a number of failings in the care that Laura received. Those findings include:

  • the expectation of rigorous attention to Laura’s safe care was not met by Arbury Court;
  • staff facilitated Laura’s means of self-harm on the day of her death by granting her unsupervised use of problematic materials, despite what was known to staff about her recent self-harming behaviour and wellbeing;
  • widespread issues in the recording of information about Laura’s risks to herself and sharing this information between the agencies involved in Laura’s care and with her family;
  • efforts to transfer Laura to a more suitable placement were hampered by the scarcity of suitable placement options and failures in information sharing between the agencies involved;
  • missed opportunities for independent scrutiny of Laura’s care through safeguarding.

The report has made eight recommendations directed at the various agencies involved, including NHS England.

Joanna Davis, Laura’s mother, said:I am devastated by Laura’s death. I believe that she was badly let down, both by Wotton Lawn who sent her so far away from home and by Arbury Court where she eventually died. After such a long wait for answers, I am pleased that the Safeguarding Adult Board’s investigation has highlighted some of the serious failures in her care. I am now looking towards the inquest into Laura’s death where I hope to finally obtain answers from those responsible for her care as to how her tragic death was allowed to happen.”
Joseph Morgan of Bindmans LLP, who represents Joanna Davis, said: “The findings of the Safeguarding Adults Review reveal numerous failures in Laura’s care, both in terms of the catastrophic decisions that led to her death and the wider management of her care by all agencies involved. Her case highlights the widespread issues across mental health services regarding failures in risk assessments, failures in record keeping and information sharing, and the inadequate provision of suitable placements.”
Selen Cavcav, Senior Caseworker at INQUEST said: "Behind so many deaths of young women in mental health care there is a history of sexual abuse and complex mental health needs. So many people in need end up waiting for months if not years for a suitable placement. Long waiting lists and lack of suitable services is simply costing lives. Three years on from Laura's death, this review is making some bold criticisms and strong recommendations which we hope will be implemented without any further delay.”


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected].

A photo of Laura is available here.

The family is represented by INQUEST Lawyers Group member Joseph Morgan of Bindmans LLP and supported by INQUEST caseworker Selen Cavcav.

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