31st March 2015



 In the South Manchester Coroner’s Court,

Mount Tabor, Mottram Street,

Stockport SK1 3PA

before HM Assistant Coroner Andrew Bridgman

7 April 2015 (the inquest is expected to last for 5 weeks)

 17-year-old Sara Green had a long history of self-harming and mental health problems which resulted in her admission to the Orchard Unit, Cheadle Royal Hospital in Stockport, a specialist unit for young people with mental health problems ran by the Priory Group.

 Sara was the victim of bullying in her teenage years and suffered from mental health problems which included a prolonged period of self harming. Despite this Sara obtained excellent GCSE results and was hopeful to go on to University.

 Sara developed Obsessive Compulsive Disorder and was initially referred to Grimsby Child and Adolescent Mental Health Service. In February 2011 she took an overdose and was subsequently placed in Ash Villa, a young person’s therapeutic unit in Sleaford as a voluntary patient. Eventually Sara was discharged home and managed in the community.

 On 12 July 2013 Sara took an overdose after a period of continued self harm.  She was taken to an adult ward in Doncaster where she ligated with a bed sheet. She was then transferred to an adult ward in Scunthorpe before being transferred to the Orchard Unit, Cheadle Royal Hospital on 17 July 2013.

 There were a number of self harming incidents involving Sara following her admission to hospital. One such incident involved a ligature and resulted in her hair being cut by staff without the consent of Sara or her family. Sara’s mother was informed that there was no other alternative to release the tension and that Sara had tried to ligate several times that night. Sara was given injections to apparently calm her down and minimise any disruption without consent from her mother.

 Sara engaged in therapy during her stay at the hospital and on occasions was allowed home leave. On 18 March 2014 a friend of Sara’s on the ward found her on the floor of her room.  Staff entered Sara’s room to discover she had ligated with a wire used to bind note pads. Despite efforts from staff and emergency response personnel, Sara was pronounced dead on 18 March 2014.

 Sara’s family hope that the quality of support and level of management she received from CAMHS and the Orchard unit will be a subject for scrutiny. The family want the inquest to address the way Sara was managed in July 2013 on adult wards and wish to have clarity as to why a decision was made to reduce Sara’s observations from once every five minutes to once every fifteen minutes by her Consultant Psychiatrist on 18 March 2014, without notifying her mother.  Amongst other issues the family also wish to clarify the discrepancies in timings of when observations were carried out that evening and the use of agency staff at the Orchard unit.


Jane Evans, Mother of Sara Green said:

 “I hope that the inquest will address my concerns about the way in which Sara was treated at the Orchard Unit. In particular, whether staff there took adequate steps to protect my daughter from the risk that she posed to herself and whether she was appropriately cared for.”

 Deborah Coles, co-director of INQUEST said:

 “This death of a young girl in a private institution, placed there because of her established vulnerabilities, must be the subject of the most robust scrutiny.”

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