This is a joint press release with Simpson Millar Solicitors

• Rachel Garrett died after falling from cliffs in Brighton
• An inquest has found there were missed opportunities to save her life
• Coroner to write to NHS England over lack of power of staff to detain mental health patients in crisis

Rachel Garrett, from Hove, was 22 years old when she died after falling from a height in Brighton on 29 July 2020. She had been in crisis and had both mental and physical health needs, including cerebral palsy.

At an inquest in Brighton which concluded today (June 2^nd, 2023), HM Coroner Penelope Schofield delivered a narrative conclusion, saying that there had been missed opportunities to save her life.

Throughout the two-week hearing evidence was heard that Rachel’s death was her sixth suicide attempt in just four weeks. Her family – who describe her as a courageous, fun, sensitive, loving person who made friends everywhere she went - had been desperately fighting to get her readmitted to a secure mental health ward for treatment and support.

However, despite their concerns, on 28 July, Rachel was taken to Royal Sussex County Hospital – instead of Mill View Hospital - after being found on a clifftop.

At 12.23am on 29 July, Rachel absconded from the hospital. She was found by police shortly afterwards and taken home. Again, her parents asked police for Rachel to be sectioned but instead she was taken back to A&E for a mental health assessment.

Rachel was placed under one-to-one supervision by a healthcare assistant, but despite demonstrating the mounting evidence of increasingly risky behaviour Rachel was able to leave the hospital again.

She was reported missing to police at 3.47pm.

An hour later, Sussex Police located Rachel on the same clifftop as the previous day. Police officers and a mental health nurse approached to talk to her, and she edged closer to the cliff edge. Rachel fell from the clifftop, and was declared dead at 6.03pm.

During the hearing Sussex Partnership Foundation Trust said that staff working in the A&E department did not have the necessary power to invoke Section 5 of the Mental Health Act, which allows for temporary detention of an informal or voluntary service user on a mental health ward.

Following the conclusion of the inquest coroner Penelope Schofield has vowed to write to NHS England to raise concerns about the issues affecting NHS Trusts and patients across the country.

Speaking following the inquest Rachel’s parents, Sarah and Andy Garrett, said that they felt that the Mental Health Services in Brighton and Hove had played ‘Russian Roulette’ with Rachel’s life.

Lawyer Chris Callender from Simpson Millar, instructed by the charity INQUEST which supported the family during the hearing, added that it was ‘contrary to common sense’ that a highly distressed young person can be permitted by mental health services to repeatedly undertake extremely high-risk visits to a cliff edge, and not be contained and treated’.

He said that a failure to put an appropriate care plan in place much sooner had proved fatal for Rachel, and thar her family continue ‘to pay the price’.

A musician who had played drums in the Brighton band grasshopper since she was 14, Rachel’s parents say that her vitality and effervescence were the beating heart of the family.

She had been a natural campaigner who had wanted to use her lived experience of disability and mental ill health to make a difference to others. She was an active ambassador for the eating disorder charity Beat and wanted to become a teacher to help other young people. She was in her second year of studying English and Education at Bath Spa.

Rachel had cerebral palsy from birth, which contributed to regular episodes of fatigue. She also had a form of neurodiversity, with unusual developmental patterns in her childhood and continued challenges with emotional regulation. In addition, she experienced disordered eating which developed into anorexia, requiring inpatient treatment in her late teens. This treatment had a positive impact, but her broader mental health challenges continued.

Her mental health significantly deteriorated at the end of her first year of university in June 2019. A few months later she was diagnosed with Emotionally Unstable Personality Disorder (EUPD), although she and her family had concerns about this diagnosis and the impact it had on the care she received.

In the months before her death Rachel increasingly felt dismissed by mental health services. Her parents say they had been forced to become near full-time carers, with little to no support from mental health services.

An extract of Rachel's diary which was read to the court during the inquest, she had written: "I am rapidly deteriorating… I don't understand how bad you are supposed to get before they help you?"

On 17 July, Rachel was found by members of the public on a clifftop, and police and a mental health nurse attended the scene. While in handcuffs and being restrained by three officers, she kicked the mental health nurse, was arrested, and taken into custody.

Whilst in custody, Rachel self-harmed despite being under constant observation. An Accident & Incident Report recorded that this was ‘to get more attention rather than a genuine attempt at suicide. ‘Rachel was released three days later despite her parents' expressing serious concerns about her safety and their ability to keep her safe.

Speaking at the hearing Dr Laurence Mylor-Wallis, an independent psychiatric expert, identified three missed opportunities to protect Rachel prior to her death.

During the hearing he told the inquest that in his opinion there should have been a detailed plan in place to protect Rachel, adding that this could have either been in hospital or in the community.

He added that ‘one of the facts that clinicians needed to weigh up was the parents' views and they were extremely worried’, saying that ‘their views absolutely needed to be taken into account in whether she needed to be detained or not’.

On 28 July, Rachel was taken to Royal Sussex County Hospital by police after being found on a clifftop. When Rachel’s mother arrived at the hospital, she was not allowed to see Rachel. She told the mental health nurse who had attended the clifftop how worried she was about Rachel’s safety if she was not sectioned under the Mental Health Act. and requested that a Mental Health Act Assessment be carried out if she wasn't.

Despite junior officers expressing their concerns to senior colleagues about Rachel's safety if the police left the hospital, the inquest heard how the police sergeant in charge said he was “willing to take the risk” and instructed them to leave the scene.

At 12.23am on 29 July, Rachel absconded from the hospital. She was found by police shortly afterwards and taken home. Again, her parents asked police for Rachel to be sectioned but officers refused. Rachel’s parents called 999 and she was taken back to A&E for a mental health assessment.

Rachel was placed under one-to-one supervision by a healthcare assistant and a plan was put in place by her doctor that should Rachel try to leave, the hospital would detain her under the Mental Health Act. Despite this, Rachel was able to leave the hospital.

She was reported missing to police at 3.47pm. The hospital did not contact her parents. Giving evidence, the independent psychiatric expert identified this hospital stay as the third and final missed opportunity for Mental Health Services to save Rachel’s life.

An hour later, Sussex Police located Rachel on the same clifftop as the previous day. Police officers and a mental health nurse approached to talk to her, and she edged closer to the cliff edge. Rachel fell from the clifftop, and was declared dead at 6.03pm.

Speaking following the conclusion of the inquest, Sarah and Andy Garrett, said: “We feel that in July 2020, the mental health services in Brighton and Hove played Russian Roulette with our daughter's life.

Too much emphasis has been placed on the day of Rachel’s death, yet in reality we had been desperately seeking help for many months. Looking to the relevant authorities to provide a comprehensive plan of action that would meet her needs. 

As her behaviour became increasingly risky, she should have been admitted to a secure mental health ward for treatment and support.

Instead, we feel Sussex Partnership NHS Foundation Trust spectacularly failed to take into consideration all of the risk factors when assessing Rachel. As her parents, they should have also taken into consideration our concerns when making decision. We should have been heard, but we felt we never were."

The family is now supporting Martha’s Rule, a new campaign to ensure patients and those closest to them are listened to and their views taken into account by healthcare professionals.

Chris Callender, a Public Law expert at Simpson Millar who represented the family, said: “The evidence that has been presented throughout the inquest with regards the care that she received, and the many, many missed opportunities to take action has been extremely difficult for them to hear.

It is contrary to common sense that a highly distressed young person can be permitted by mental health services to repeatedly undertake extremely high-risk visits to a cliff edge and not be contained and treated. 

Tragically, for Rachel, that failure to put an appropriate care plan in place much sooner proved fatal, and her family continue to pay the price.

Sadly however, they have found that they are not alone in their grief, and that many other families have also been impacted as a result of mental health services failings – both in Sussex, and across the country.

It is their hope that genuine lessons are learnt by both the police and Sussex Partnership NHS Foundation Trust further to the conclusion delivered by the coroner, and that changes are put in place urgently so that people in crisis can access the care and support that they need, when they need it most.”

Caroline Finney, Caseworker at INQUEST, said: “Rachel was repeatedly failed by the services tasked with keeping her safe. Like so many other young women, her distress was dismissed and ignored to the extent that a police officer was willing ‘to take a risk’ on her safety.

Her death will be added to the long list of young women who died trying to access support. Their stories must be the wake-up call that leads to investment in non-punitive mental health care and crisis intervention teams, delivered with and by communities.”

ENDS

NOTES
For further information please contact the PR consultant acting on behalf of Simpson Millar - Ashlea McConnell, [email protected] 07852282802.

The family is represented by INQUEST Lawyers Group members Chris Callender of Simpson Millar and Emma Favata from Garden Court Chambers. The family are supported by INQUEST caseworker Caroline Finney.

Other Interested Persons represented include: Sussex Partnership Foundation NHS Trust (SPFT), University Hospitals Sussex NHS Foundation Trust (UHSNHSFT), Sussex Police and the Independent Office for Police Conduct (IOPC), Rachel’s GP.

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

Deaths in the care of Sussex mental health services:

• The Telegraph reported in January 2022 that more than 360 patients took their own lives after being treated by Sussex Partnership Foundation NHS Trust in the past five years. While there were also 15 coroner’s reports to prevent future deaths.
• Bethany Tenquist, 26, died after ligaturing in her room at Mill View Hospital (where Rachel was also treated at points) on 16 January 2019. An inquest found a sequence of serious failures relating to staffing, leadership and safeguarding processes on ward probably had a direct causal connection to her death. Media release.
• Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care. Media release.
• In 2016, local media reported that five women had died at Mill View Hospital, including Janet Müller (above), Danuta Corbett, Jessica Philpott, Jackie Stansby, and Philippa Mortiz-Parsons.
• Sabrina ‘Sabby’ Walsh, 32, died on the Woodlands Ward in Sussex 2016. The inquest found gross failures and neglect contributed to her death. Media release.
• Bethan Smith, 31, died whilst under the care of Sussex Partnership Trust in 2011. Her mother wrote this about their experiences.