29th April 2015


In the South Manchester Coroner’s Court,

before HM Assistant Coroner Andrew Bridgman

7-28 April 2015


The Coroner concluded the inquest into the death of Sara Green yesterday, finding that the lack of a tier 4 mental health bed available for Sara in the months preceding her death was a factor that contributed to her death. At the date of Sara’s death she had been an in-patient for 9 months despite having been considered ready for discharge within 3 months of admission. The Coroner, Mr Andrew Bridgman, said that this was due to a lack of NHS placement and a failure to manage her discharge. He concluded that this was a contributory factor to the act of self harm that ended her life.

Sara Green was a 17 year old patient at the Orchard Unit of the Priory Group Cheadle Royal Hospital in Stockport from July 2013, where she had been admitted because of self-harming. Sara had a history of harming herself since the age of 13 and had been in contact with mental health services since then. Sara harmed herself repeatedly even after her admission to The Priory by cutting and by ligaturing.

Sara was admitted to the privately run Priory Hospital, paid for by the NHS, as there were no NHS beds available. She had previously been in an adult ward in Scunthorpe. The Hospital was 100 miles from her family home despite the fact that she benefitted from close family ties and that her anxiety was worsened by not being in a community or an alternative psychiatric institution closer to her home. On admission to the Priory it had been Sara’s and her family’s expectation that she would be assessed and treated there for 6-8 weeks. Sara in fact remained there for 9 months due to a combination of the failure to manage her discharge and the shortage of NHS beds.

On the evening of the 18 March 2014, Sara was discovered in her hospital bedroom with a ligature. Sara was discovered in a collapsed and unresponsive state by a 13 year old child patient who had been worried about Sara. Despite medical intervention, she could not be resuscitated.

Sara’s mother, Ms Jane Evans, had written a letter to the Priory Hospital in January 2013 in which she highlighted several occasions when Sara had suspended ligatures and self-harmed in the Hospital, leading to A&E visits. She expressed ‘extreme cause for concern’ that the Hospital’s care and treatment of Sara was inadequate. The Hospital made no substantive reply until 30 April 2014, some six weeks after Sara’s death.

Sara had previously used the same type of ligature that caused her death. On that occasion she was rescued by staff who used oxygen to revive her. The Court heard that the Hospital failed to consider whether the item used should be a banned item; failed at any time to conduct a risk assessment to determine whether Sara could safely possess a book with wire binding; and failed subsequently to inform all staff caring for Sara of the incident.

The coroner was highly critical of the fact that Sara had been allowed to obtain an item containing the ligature after her previous attempt to self harm with the same. The Coroner noted he had no doubt that had Sara used this item at home her mother would never have allowed her to have access to such a thing for a long time afterwards.

The day before Sara died she had returned to the hospital from a period of home leave. She did not want to return to the Hospital and had self-harmed by cutting at home on the Friday before. Hours before Sara’s death, her clinical psychiatrist Dr Mahdev Jasti, who continues to work at The Priory, decided to reduce the levels of observation by staff upon Sara, despite knowing of several risk factors present, including the fact that she had been categorized as “high risk” of self-harm or suicide only hours before her death.

The Court heard that the Hospital had no coherent policy on how or how regularly observation should be conducted, and the staff at Orchard Unit were conducting observations in breach of the Priory’s own national policy. The Coroner concluded that the correct observation policy was not taught at induction training.

The inquest heard that confusion as to the meaning and frequency of observation levels is widespread nationally and is a subject of concern.

The Coroner stated that he would write to the Chief Executive of the Priory Group to formally express his concern at what he referred to as the deplorable practice of inadequate medical record keeping that he considered to be so inadequate as to risk the possibility of future deaths.

The Coroner said that he was also considering writing a prevention of future deaths report in relation to the inconsistent approach to observations at the Cheadle Royal Hospital and ruled that the Priory must assure the coroner that a new policy is in practice.

Jane Evans, mother of Sara Green said:

“I remain extremely worried that other adolescents with mental disorder are at risk of fatal self-harm in psychiatric hospitals managed by the Priory group.

I can not understand why the Priory failed to provide to Sara the care she needed for her mental health and safety; why no safe system of care was in place; why staff responsible for observing Sara on the night of her death did not know and had not been told what they were supposed to be doing; and why several of the failings by The Priory have only been exposed at the inquest hearing and were not detected during The Priory’s own internal investigation.

I am disappointed that the coroner has not found more of these failures to be causative in sara’s death, in particular in relation to the fact that there was no risk assessment of Sara having a wire bound notebook in her possession, despite the fact that the coroner found that had there been it would have been added to the list of banned items.

It is significant that the coroner was highly critical of numerous failings in the care and treatment of Sara by the Priory.”

Deborah Coles, co-director of INQUEST said:

“The self-inflicted death of a vulnerable teenager in a mental health setting is deeply shocking. 17 year old Sara was sent to a privately run hospital at great distance from her family because there were no NHS beds available. The new government must address such dangerous inadequacies in our system of mental health care for children and young people.

Two months before her death, Sara’s mother raised concerns about the treatment Sara was receiving and the Priory run hospital failed to respond until after she died.

The failings that the coroner has identified are deeply troubling. Moreover it is also alarming that the Priory’s internal investigation did not identify the failings found by the coroner in this inquest. This only reiterates the need for more independent investigation and effective scrutiny of deaths in mental health settings to identify learning in order to safeguard lives in the future.”


Gemma Vine, solicitor for the family, said:

“This is a very sad case involving the death of a highly vulnerable young girl in a private mental health unit which could and should have been avoided. This case highlights not only the failings by staff at the Priory to protect Sara but also a national problem regarding the lack of provisions and funding in place to properly support vulnerable young adolescents.

This is yet another death which demonstrates the inadequacies in our current systems for the provision of mental health care for children and young people which is in dire need of an overhaul.”


INQUEST has been working with the family of Sara Green since her death in 2014.  The family is represented by INQUEST Lawyers Group member Gemma Vine from Lester Morrill Solicitors, and Nick Stanage from Doughty Street Chambers.