10 April 2024

Before HM Area Coroner Dr Peter Harrowing
Avon Coroner’s Court, Bristol
Opening 15 April 2024
Scheduled for 10 days

Lily Lucas, 28, died after being found unresponsive whilst an NHS inpatient at a privately run Cygnet Hospital in September 2022. Now an inquest will open to examine the circumstances of her death and the care she received.

Lily’s family describe her as beautiful, loving, generous and hilarious. She had worked as a registered mental health nurse. Her family felt her kindness and compassion to others and her great sense of humour were her superpowers. 

Lily had a long history of mental ill health and a diagnosis of schizophrenia. She had hoped this hospital admission would be an opportunity to get better.

On 15th June 2022, Lily was admitted to Milton Ward at the Cygnet Hospital at Kewstoke, Weston-super-Mare under Section 3 of the Mental Health Act 1983, after an escalation in her mental health symptoms. She initially made good progress, but her mental health again deteriorated around August 2022. 

On 5th September 2022, Lily was prescribed Clozapine to help manage her symptoms. This is a drug that Lily was scared about taking, as she was aware of the severe side effects some people suffered. Her family raised her concerns with the treating team.

In the hours leading up to her collapse, Lily was seen to drink excessive volumes of fluid and to eat excessively large quantities of food. This was very uncharacteristic behaviour for Lily. Despite this, there was no escalation in her care. 

Unfortunately, in the evening of 8 September 2022, Lily was found unresponsive in her room and after CPR was transferred to the Bristol Royal Infirmary for treatment. She subsequently died on 9th September 2022. 

The inquest is set to focus on the care Lily received at Cygnet in the lead up to her death and in particular:

  • the prescribing and monitoring of antipsychotic medication, particularly Clozapine;
  • the events of the days immediately prior to her collapse and the actions taken by those caring for her, particularly in relation to the obvious deterioration in her physical and mental health and the response of staff at Cygnet Hospital to intervene or to escalate for help;
  • the emergency response following Lily’s collapse.

Lily’s family said:After a long and complex battle with her mental health, Lily was ultimately diagnosed with schizophrenia. This is a mental illness that is not well understood by our society and as a result has many negative connotations. 

Despite her illness, Lily was like any other 28 year old with hobbies, ambitions and a family and friends that loved her. Lily was so much more than the illness which will be the focus of this inquest. 

She had worked as a registered mental health nurse so it’s especially heartbreaking for us that mental health services failed her in her time of need when she had dedicated so much of her time and energy to caring for others in a similar situation.

Lily was beautiful, loving, generous and hilarious. She was so carefree and fun, and so full of mischief. Lily loved her family and would tell us every single day. Her kindness and compassion to others and her great sense of humour were her superpowers. 

Lily saw her admission to Milton Ward, at the Cygnet Hospital as an opportunity to get better for good as she would have access to all the therapeutic support she so needed. We trusted Cygnet to care for her, and the fact they significantly let her down in her time of need compounds our grief and despair. 

Lily leaves behind a family who could not have loved her more. Our loss is immeasurable and often overwhelming. Life will never be the same without our beautiful daughter and sister. We are traumatised by the loss of Lily. Our utter devastation impacts us all, both physically and mentally as we struggle to navigate a painfully different life without her.

We are deeply concerned by the failures which have been identified by the hospital’s internal investigation and hope no other family has to read similar things about their loved one. 

We sincerely hope and expect that the inquest will fully investigate the circumstances surrounding Lily’s tragic death and highlight those areas that need to be improved to ensure the safety of other patients at the Cygnet Hospital and other mental health facilities looking after vulnerable people like Lily.” 



For more information please contact Leila Hagmann on [email protected].

The family are represented by INQUEST Lawyers Group members Ali Cloak, of RWK Goodman and Marcus Coates-Walker of 1 Crown Office Row.

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