3 November 2023

Before HM Coroner Sonya Hayes
Essex Coroner’s Court, Seax House
Opens 6 November 2023
Scheduled to last 3 weeks

Morgan-Rose Hart died shortly after her 18th birthday on 12 July 2022 whilst an inpatient at an Essex mental health hospital. Now an inquest will open to examine the circumstances of her death.

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

Morgan-Rose had a history of mental ill health and self harm and was known to social services. She also had an autism diagnosis and ADHD. 

Morgan-Rose's mental health was affected by bullying at school and she moved school several times as a result. Following the death of her much-loved grandmother in 2019, Morgan-Rose's mental health began to deteriorate.

Morgan-Rose was detained under the Mental Health Act (MHA) for the first time in May 2020, and placed in an acute Child and Adolescent Mental Health Services (CAMHS) ward at the Priory.

In January 2021, Morgan-Rose was admitted to another acute CAMHS ward at the St Aubyn’s Centre.

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. 

In December 2021, Morgan-Rose was transferred to an acute ward in Potter’s Bar where she was placed under constant observation by two members of staff. 

Three weeks prior to her death, Morgan-Rose was transferred to the Derwent Centre, an adult mental health unit, where she was initially placed under 1:1 observations. Within three weeks it is understood she was moved from 1:1 observations to hourly observations.

On 6 July 2022, Morgan-Rose was found ligatured by staff. Emergency services were called and Morgan-Rose was transferred to Princess Alexandra Hospital. She died in hospital six days later.

The inquest will now examine the issues arising from the care Morgan Rose received. 


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 Solicitors 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) and Essex County Council.

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. 

  • 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.
  • 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.
  • 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.