26th October 2012

10am Monday 29 October 2012 before HM Coroner for Central and South East Kent District, Rachel Redman, sitting at Dover Magistrates Court, Pencester Rd Dover CT16 1BS

The inquest into the death of Robien Winchester will commence on Monday 29 October 2012. It is listed for one week.

37 year old Robien Winchester died on 6 March 2011. At the time of her death, Robien was an in-patient at the Arundel Unit, the psychiatric unit of William Harvey Hospital, Ashford, Kent. Robien was admitted to the Arundel Unit on 27 January 2011 following an episode of depressive instability. On the day of her death, Robien had returned to the hospital in a state of distress and under the influence of alcohol. She was allowed to leave the unit again at 19.55 whilst still under the influence of alcohol. She failed to return and was later found dead.

Following Robien’s death, a police investigation was started, which included concerns about the number and frequency of patients going missing from the Arundel Unit. Since Robien’s death, two further deaths have occurred of patients from the Arundel Unit: Sam Lee on the 5th October 2011 and Craig Wallis on 11 April 2012.

An investigation into the circumstances of Robien’s death was conducted by Kent and Medway NHS and Social Care Partnership Trust, the same Trust that had responsibility for her care. Robien’s family were given no opportunity to have input or any involvement in that investigation. The investigation produced a brief report which concluded that no root cause review² was necessary.

Following a long and painful wait, Robien’s family welcome the inquest as a first opportunity to independently examine the facts surrounding her tragic death and to explore whether she received appropriate levels of care. In particular they hope the inquest will look at:

1.Whether the Trust were operating full and proper care and risk procedures concerning informal patients, including around the grant of leave;

2.Whether the Trust conducted appropriate assessments of Robien and put in place suitable levels of care and control to ensure her safety;

3.Why, given obvious risk concerns, Robien was allowed to leave unescorted on the evening of her death;

4.Why, when Robien failed to return to the unit, the Trust had no knowledge of her whereabouts and, despite fellow patients raising the alarm earlier, why she was not reported missing sooner.

Robien’s family is being represented by Jenni Richards QC of 39 Essex Street Chambers, instructed by INQUEST Lawyers Group member Sara Lomri of Bindmans LLP.

Notes to editors:

  1. Robien Winchester’s family and their representatives will not be making any comment to the media while the inquest proceedings are ongoing. Any enquiries should be directed to Sara Lomri.
  2. From National Patient Safety Agency, February 2008 “Root cause analysis (RCA) is a technique which can be used for undertaking a systematic investigation. It looks beyond the individuals concerned and seeks to understand the underlying system features and environmental context in which the incident happened… RCA is designed to identify the sequence of events that led to the incident. This allows the underlying causes of the incident to emerge so that organisations can learn and put remedial action in place. A root cause is the cause or causes that if addressed will prevent or minimise the chance of a similar incident recurring in the future”.

In contrast to all other custody settings, no organisation exists to independently investigate pre-inquest the deaths of those who die in mental heath hospitals. There is no equivalent of the Independent Police Complaints Commission or Prison and Probation Ombudsman to investigate those deaths.