1 November 2021

Media release prepared by Bhatt Murphy Solicitors

An inquest jury at Hertfordshire Coroner’s Court returned a conclusion today that Elysium Healthcare Ltd.’s failings contributed to the death of 16 year old Nadia Shah on 15 January 2019, following her detention under the Mental Health Act at the secure unit in Potters Bar, Hertfordshire.

Elysium Healthcare Ltd. is a private mental health provider, commissioned to provide secure care to NHS patients in numerous units around the country. Nadia’s death is one of four INQUEST cases involving failures in their care, and is part of a larger pattern of deaths of children and young people in the care of private mental health providers.

Due to Nadia’s risk of self-harm, her consultant psychiatrist required her to be observed at least every 15 minutes. However, on 12 January 2019 she was not checked for over 19 minutes when she was found in breathing difficulties with a ligature she had placed around her neck.

The chaotic scene that ensued led to a delay in Nadia receiving basic life support measures such as chest compressions and rescue breaths. The jury was also critical of Elysium’s unsatisfactory implementation of Nadia’s care plan and its failure to sufficiently provide her with cohesive care. The jury concluded that all of these factors contributed to her death.

Nadia was transferred from Elysium Potters Bar to Barnet General Hospital where she died on 15 January 2019 from the brain injury she sustained due to events at Elysium on 12 January 2019. The Care Quality Commission will now consider whether Elysium should be the subject of a criminal prosecution for breach of health and safety legislation.

Nadia had a history of mental ill-health and had been a detained in-patient at Elysium since October 2018. A keen footballer, Nadia had an orange belt in martial arts and had planned to train as a social worker in order to help other vulnerable young people.

Nadia’s mother Lorraine Shah said “Nadia lit up our lives and will stay in our hearts forever. I am determined that Elysium should not be allowed to let other vulnerable children die in their custody. The jury’s conclusion shows that it is not safe for the NHS to place a child at risk of self-harm like Nadia at Elysium.”

Nadia’s sister Jasmine Shah said: “Nadia was loved deeply and will never be forgotten. Her spirit lives on in our search for justice in her name. We now call on the Care Quality Commission to ensure that Elysium faces the full force of the criminal law.”

Tony Murphy of Bhatt Murphy the family’s solicitor said: “The Care Quality Commission has been monitoring these inquest proceedings with a view to considering whether Elysium should face a criminal prosecution for any health and safety breaches which contributed to Nadia’s death. The family seeks an early meeting with the CQC to ensure that justice is served without delay.”

Deborah Coles, Director of INQUEST said: “Nadia is among far too many children and young people who have died preventable deaths 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 children’s mental health, we cannot continue to allow companies to put their profits before our children’s safety.”



Any requests to contact the family should be emailed to [email protected]

The family were represented by Sam Jacobs and Rosa Polaschek of Doughty Street Chambers instructed by Tony Murphy and Erica San of Bhatt Murphy Solicitors.

Other Deaths in Elysium facilities: 

  • Brooke Martin,19, died whilst a patient at Chadwick Lodge hospital run by Elysium in 2019. An inquest in July found there were communication, ligature risks, and observation issues. See media release. 
  • Leon Tasi,21, died a self-inflicted death at Chadwick Lodge in July 2020. It appears there were issues around observation levels and care planning. The inquest into his death is taking place at Milton Keynes coroner’s court from 1 November 2021.
  • 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. See media release.