15 December 2023

Before HM Coroner Sonya Hayes
Essex Coroner’s Court, Seax House
6 November – 1 December 2023 

Morgan-Rose Hart died shortly after her 18th birthday on 12 July 2022 after ligaturing whilst an inpatient at the Derwent Centre, an Essex mental health hospital. An inquest has found that neglect contributed to her death. 

Morgan-Rose was from Chelmsford, Essex. An aspiring vet, Morgan-Rose had a huge passion for animals and wildlife. Kind and funny, her family said that Morgan-Rose would often put others before herself and helped many other young people during her own difficult times. 

From a young age, Morgan-Rose had difficulty regulating her emotions and showed signs of social anxiety. She was later diagnosed with autism and ADHD. Despite a referral to Child and Adolescent Mental Health Services (CAMHS) aged 10, she was not given any support. There were severe delays in her eventually receiving support. 

Morgan-Rose's mental health was badly affected by bullying, and she moved school several times as a result. In 2019, Morgan-Rose's mental health began to deteriorate, and her Body Dysmorphic Disorder (BDD) became unmanageable. From 2020 onwards, Morgan-Rose experienced multiple admissions to hospital under section.  

In May 2021, Morgan-Rose was admitted to Broomfield Hospital following several attempts to take her own life. She was subsequently sectioned and transferred to Poplar Ward, Rochford Hospital, when a bed became available.

She was placed in the High Dependency Unit on long term segregation with two members of staff observing her at all times. Morgan-Rose's mother had serious concerns about her safety whilst here and the harmful impact of this period of detention on Morgan-Rose's mental health. 

On 9 December 2021, Morgan-Rose was transferred to an acute ward in Potter’s Bar, where she was able to abscond whilst on escorted leave and on at least one occasion was found ligatured despite being on constant observation.  

Morgan-Rose’s mother gave evidence at the inquest that Morgan-Roses’s transition from CAMHS to adult mental health services was a difficult and uncertain time for her, causing agitation, distress and further self-harm. Morgan-Rose’s mother repeatedly raised concerns about her increasing risks.  

A number of professionals involved in her care (including her care co-ordinator) expressed repeated and serious concerns regarding the suitability of an adult acute mental health unit, in the absence of a supportive community placement, for young woman with Morgan-Rose’s diagnosis of autism, and her vulnerabilities. 

Chelmer Ward, the Derwent Centre 

Shortly after her 18th birthday, and only three weeks prior to her death, Morgan-Rose was transferred to Chelmer Ward at the Derwent Centre in Harlow, an adult acute mental health unit run by the Essex Partnership University NHS Foundation Trust (EPUT). 

Morgan-Rose told her consultant psychiatrist that she was scared of being on a large acute adult ward. She spent the vast majority of her three weeks there in her room and in that time her observation levels were reduced from constant, to hourly. Morgan-Rose's mother was not informed that her observations had been reduced. 

On the afternoon of 6 July 2022, at approximately 15:30 after notifying staff that she was going to take a shower, an automated alert was sent by Oxevision. This is a vision-based patient monitoring system that uses infrared-sensitive cameras in inpatient bedrooms on mental health wards. This alerted staff that Morgan-Rose had been in the bathroom – a blind spot and recognised risk area – for three minutes.  

The alert was subsequently reset, without a physical check of Morgan-Rose's safety being carried out, despite EPUT policy mandating this. No member of staff accepted responsibility for this action at the inquest. A member of the EPUT Patient Safety team confirmed that there is a risk the staff member in question could still be working for the Trust, and that this was “a concern. 

At around 16:20, 50 minutes after the alert was disabled, Morgan-Rose was found unresponsive in her bathroom on Chelmer Ward, having ligatured.  

Following an emergency response, Morgan-Rose was transferred by ambulance to Princess Alexandra Hospital where she suffered several further episodes of cardiac arrest. She was declared dead following brainstem death testing on 12 July 2022, as a direct result of what happened on 6 July.  

The jury concluded that Morgan-Rose died as a result of neglect as a result of a failure of basic protocol and procedure documented by EPUT. In their narrative conclusions they found that: 

  • Morgan-Rose’s transfer from child to adult services was not sufficiently supported; and on transfer, information about her medical history, diagnoses, and triggers were not filtered down to the staff who were providing her day to day care; 

  • Nobody removed risk items from Morgan-Rose at any time during her three weeks on Chelmer Ward, despite the fact that she arrived on constant observations due to her high risk of self-harm, including a history of ligaturing;  

  • There was no subsequent risk assessment of Morgan-Rose’s property when her observation levels were downgraded; 

  • There were no records of meaningful therapeutic engagement with Morgan-Rose, despite the observation records being signed off by nursing staff;  

  • There were no risk assessments made concerning Morgan-Rose’s triggers for self-harm 

  • Food and fluid charts were inadequately completed, despite concerns that Morgan-Rose was losing weight;  

  • There was no escalation of, and no change was made to, Morgan-Rose’s observation levels when she attempted to access unescorted leave without the permission of her Responsible Clinician on the morning 6 July 2022; 

  • Observations were falsified by staff in the observation records, meaning that although she was on hourly observations, Morgan-Rose’s last physical observation took place at around 14:06 on 6 July 2022 

  • Most ward staff stated they were not trained to use Oxevision, but despite this “Observations [were] mainly being completed via the Oxevision system” in breach of EPUT policy; and 

  • No staff member attempted to make a physical welfare check on Morgan-Rose until she was discovered in the bathroom at 16:20. 

Systemic issues

The jury heard evidence over the course of the inquest that senior management within EPUT were ostensibly unaware of the concerning practices on Chelmer Ward. This included the inappropriate use of Oxevision, and the inadequate completion of documentation including observation charts and food and fluid charts.  

Staff employed by EPUT routinely did not carry out face-to-face checks on Morgan-Rose, the inquest heard, with three workers admitting to falsifying observation notes from the day of the incident.

Evidence was also heard during the inquest regarding the findings of a 2022 CQC report on EPUT, where acute wards for adults of working age run by EPUT – such as Chelmer Ward – were rated inadequate, the lowest possible rating, on safety and leadership. 

The CQC raised concerns about the safe and effective observation of patients, failures to address issues of staff not following policies, or to ensure adequate levels of compliance with mandatory training, and failures to respond to patient safety incidents well, or to manage patient risks well. The CQC also raised questions regarding “how robust and effective the Trusts governance and monitoring systems are. 

The jury heard evidence from a member of the Trust’s senior management team, Elizabeth Wells, that although the Patient Safety Incident Investigation report prepared following Morgan-Rose’s death did not cover all areas of concerns, and contained “omissions”, the report was signed off in spite of this.  

Morgan-Rose’s mother and INQUEST also raised concerns in correspondence to the Trust’s CEO regarding the poor quality of the report, and the investigation, but no further action was taken to address these shortcomings.  

During the inquest, the jury complained to the Coroner that members of EPUT staff were intimidating them by staring at them, and that two witnesses had high-fived after giving evidence whilst still in court. The Coroner also issued reporting restrictions following concerns about EPUT witnesses colluding, corroborating or seeking to interfere with each other’s evidence. 

The Coroner has expressed an intention to make a prevention of future deaths report following the inquest’s conclusion. 

Michelle Hart, Morgan-Rose's mother, said: Morgan-Rose was an incredible vibrant daughter and sister. This world has lost one of the best, and life will never ever be the same without her. She will remain in our lives in every other way possible.  

We hope EPUT and Essex County Council finally learns from its failures so that no other family has to go through what we've been through.” 

Jodie Anderson, Senior Caseworker at INQUEST, said: It is truly shocking that a Trust already subject to such scrutiny by way of a statutory public inquiry, critical CQC report and criminal prosecution can continue to neglect vulnerable teenagers such as Morgan-Rose. 

The evidence gave insight into a deeply dysfunctional, chaotic and unsafe ward. The conduct by EPUT staff and management during this inquest was abhorrent and screams of a culture of inhumanity towards bereaved families. Morgan-Roses death and the failures this inquest uncovered are emblematic of a wider crisis in mental health care. 

A lack of willingness to learn from repeat failures and previous deaths tells us all we need to know about an organisation that prioritises reputation management over patient safety. More must be done to hold failing Trusts to account and ensure that those most in need are able to receive safe, therapeutic care. 



For further information, interview requests and to note your interest, please contact Leila Hagmann on [email protected] 

The family are represented by INQUEST Lawyers Group members Rachel Harger and Khariya Ali of Bindmans LLP and Tom Stoate of Doughty Street Chambers. The family are supported by INQUEST senior caseworker Jodie Anderson. 

Other Interested persons represented are Essex Partnership University NHS Trust (EPUT), Essex County Council and Oxehealth. 

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

Deaths in Essex mental healthcare: 

Since 2021, there is an ongoing inquiry into Essex Mental Health services. Following years of campaigning from bereaved families, the inquiry has now relaunched with statutory legal powers. See the Essex Mental Health Independent Inquiry website for the latest update 

  • Marion Michel, 56, died of self-inflicted injuries on 4 March 2022 whilst an inpatient at Brockfield House, a secure mental health unit in Essex. An inquest found that the absence of a specific risk assessment may have contributed to her death. Media release. 
  • Chris Nota, 19, had been under the care of Essex mental health services when he died on 8 July 2020 after falling from a height in Southend. An inquest found that multiple failures in care contributed to his death. Media release. 
  • Edwige Nsilu, 20, died on 5 February 2020 after being found unresponsive at St Andrews Healthcare Essex. An inquest concluded that neglect contributed to her death. Media release. 
  • Darian Bankwala was 22 years old when he was discharged from EPUT mental health services at Rochford Hospital four months prior to his death on 27 December 2020. Darian had learning difficulties and some autistic traits which an inquest heard were never properly investigated or diagnosed. Media release. 
  • Bethany Lilley was 28 when she died whilst an informal patient on Thorpe Ward at Basildon Mental Health Unit on the evening of Wednesday 16 January 2019. The inquest in March 2022 concluded that her death was contributed to by neglect due to a plethora of failings by Essex University Partnership Trust. Media release. 

In 2021, EPUT was prosecuted in relation to health and safety failings concerning ligature points. The Trust was fined £1,500,000. Sentencing remarks.