8 November 2021

Before Her Majesty’s Senior Coroner Tom Osbourne
Milton Keynes Coroner’s Court

1 – 4 November 2021

Leon Tutoatasi Mose Tasi, 21, was sadly pronounced dead on 10 June 2020 whilst detained under the Mental Health Act and under the care of Elysium Healthcare at Chadwick Lodge, Milton Keynes.

Leon was born in Salailua, Samoa and moved to the UK at about 2 years of age.  Leon was full of life, energetic, loved joking around and playing sports.  He had a loving, supportive family with two adopted sisters living in London. In his last few years he became closer towards his biological parents, eight siblings and extended family in Samoa. He was very protective, kind hearted and supportive towards his sisters and friends.

Leon’s mental health and behavioural difficulties dated from when he was 13 and was placed under the care of children and adolescent mental health services (CAMHS). He was diagnosed with Emotional Unstable and Dissocial Personality Disorder and detained under the Mental Health Act at various establishments from the age of 17.

On 11 May 2020, Leon was transferred from a medium secure unit to a low secure unit: Lymington Ward, Chadwick Lodge.  Leon was initially on one to one constant observations (level three), but this later reduced to general observations which are hourly.

Leon was making good progress as he was working towards a family reunion trip to Samoa in 2021. He also wanted to live independently. Due to his Personality Disorder, he would feel emotionally overwhelmed by various matters. He would struggle to cope with these emotions and thus become frustrated or agitated, sometimes self-harming as a coping mechanism.

During the early hours of 10 June 2020, Leon’s general observation was carried out at 4.04am by staff. It was recorded that he was “In bed lying on bed, chatting on phone.”  It was confirmed in evidence, and via CCTV footage, that no visual observation was in fact carried out of Leon. As Leon could be heard on the phone, staff informed the Court and jury that there was no requirement to carry out a visual check. The policy at Elysium Healthcare has now changed and stipulates that all observations must include a visual check on the patient.

Leon was talking on and off to his mum until 4.15am. At approximately 4.17am Leon self-ligatured using a personal item. 

Nursing staff at the inquest confirmed that there is no live feed of the CCTV footage within the nurse’s office. When staff are in the nurse’s office, they can see to the end of the corridor, but can only hear noises if they are loud. It was further explained that events occurring in the corridor can only be heard from the lounge area.

Leon's mum and dad called and texted him several times, but after no reply, they notified staff at 4.35am to check on Leon, as he might be self-harming. 

Staff attended Leon’s room and noticed the item at the top of the door.  A number of tools were utilised to cut the ligature and open the door to gain access to Leon. Due to the position of the ligature, it took nine minutes to open the door and get to Leon. CPR was commenced and an ambulance called. Leon was taken to Milton Keynes Hospital but sadly pronounced dead that morning.

It was confirmed that the policy of Elysium Healthcare is that an ambulance is not called until a qualified nurse has made a full assessment of the patient. 

The jury returned a conclusion of 'suicide whilst suffering from a psychiatric illness' and concluded that nursing staff carried out his general observation at 4.04am, but Leon was not visually observed.

One main issue which arose in Leon’s case, as well as in the case of Brooke Martin who sadly also passed away whilst under the care of Elysium Healthcare at Chadwick Lodge, is the awaited guidance on built and therapeutic environments and the use of door pressure sensors. The National Confidential Inquiry into suicide and safety in Mental Health identified that doors are the most common ligature point, with 51% of inpatient deaths using this method of ligature.

NHS Resolution have also identified that NHS Trusts are frustrated by the absence of guidance on the built environment, which is causing “inadequacies in the physical environment”. Guidance was due to be provided by NHS Improvement in June of this year, but has not yet been published.

Linda Tasi, Leon’s mother said: "The pain of missing Leon is still present. He has missed out on a life of new experiences, relationships, having his own children/grandchildren and growing old with loved ones.

My concern is that Leon was progressed too quickly and that he felt he was under a lot of pressure to succeed and didn’t want to be set back. This was his first time improving and he told me he was trying to avoid anything, even asking for anti-depressants, that would put him back and stop him from going back to the community and reuniting with his family in Samoa, New Zealand and the United States.  I feel that, underlying, he was in a pressure cooker and didn’t dare to express this to staff.

Despite the many transfers to care homes and hospitals, we continued to have high hopes from the professional care and treatment. However 5–6 years later with Leon’s complex personality disorder established, we feel with this result, his underlying issues were not dealt with enough and even underestimated after reading the reports. Leon had a clear recurring history of incidents, sometimes delayed reactions, which tended to linger and were expressed in an unpredictable and impulsive way.

I want to raise awareness and ensure that no family has to go through what we have been through. New guidance needs to be given immediately. Such a simple measure as a door pressure sensor, or any other alternative measures or methods could save many lives, maybe even Leon’s.”

Jenny Fraser, the solicitor representing the family, said: "This is yet another tragedy of a life lost. There has already been three other recent deaths within Elysium facilities:

  • Nadia Shah, 16, died whilst a patient at a secure unit in Potters Bar, Hertfordshire. An inquest last week concluded Elysium Healthcare Ltd.’s failings contributed to the death. There were issues around delayed observations, access to ligatures, and issues in basic life support responses.
  • Brooke Martin, 19, also died whilst a patient at Chadwick Lodge in 2019. An inquest in July found there were communication, ligature risks, and observation issues.
  • Laura Davis, 22, died a self-inflicted death in Arbury Court, one of Elysium’s facilities in Warrington. Laura, like Brooke Martin, was awaiting transfer to a more suitable placement. A Safeguarding Adults Board identified failures in the care she received.

These are too many deaths. I therefore echo the sentiments of Mrs Tasi that the use of measures, such as door pressures sensors, could save so many lives and could have in fact saved Leon’s life. It is hoped that this guidance is provided immediately so that life saving measures can be put in place to ensure deaths are prevented and families can live a life they deserve with their loved ones.

Deborah Coles, Director of INQUEST, said: “Leon is one of far too many young people to have died in concerning circumstances whilst under the care of private mental health services, including Elysium, in placements funded by the NHS.

Inquests consistently expose that these private providers are failing, whilst they continue to make profit and win contracts. Ministers and regulators are also failing to respond to repeated failures and hold these companies to account. If we as a country are serious about the mental health of children and young people, we cannot continue to allow companies to put their profits over safety.

INQUEST have seen too many recent deaths across the country which may have been avoided with the installation of door pressure sensors. These cases clearly point towards an urgent need for national guidance on door-top sensors as mitigating this ligature point could prevent further unnecessary deaths.”


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

Leon's family are represented by INQUEST Lawyers Group members Jenny Fraser of Fosters Solicitors and Stephen Clark of Garden Court Chambers. The family are supported by INQUEST caseworker, Nancy Kelehar. 

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