19th November 2013

An inquest jury at Surrey Coroners Court has concluded that a 26 year old local woman, Sarah Shepherd, died in hospital on 13 September 2011 as a result of failings by Surrey and Borders Partnership NHS Foundation Trust. Sarah, a gifted PhD student with a first from Oxford, was  found with a plastic bag tied over her head on 12 September 2013 in her room at the Noel Lavin Unit (since closed), Farnham Road Hospital in Guildford, whilst detained under section 3 of the Mental Health Act. An ambulance was called and Sarah was transferred to the Royal Surrey County Hospital in Guildford where she was pronounced dead on 13 September 2011. 

During the course of her detention at the Unit between 26 June and 12 September 2011, Sarah had been found by ward staff attempting to self-harm on multiple occasions, including on six prior occasions in September 2011 with a plastic bag. Notwithstanding, bin liners were not removed from Sarah’s room, her level of observations were not increased, and a referral to the Psychiatric Intensive Care Unit was not made. The inquest jury found that each of these failings contributed to Sarah’s death.

HM Coroner Hewitt announced that she would be making a ‘Prevention of Future Death’ report to the Trust and the Secretary of State for Health regarding her concerns in relation to the adequacy of basic life support training provided to Trust staff by an external agency ‘Back to Life’ Ltd; and regarding the adequacy of the Trust’s ongoing procedure for making referrals to the Psychiatric Intensive Care Unit.

Sarah Shepherd's family said:

“The Trust failed to protect Sarah, thereby denying her a chance to get better. That’s all she ever wanted and she had so much to give.”

The family's solicitor Tony Murphy of Bhatt Murphy said:

“The failure of basic care that contributed to Sarah’s death is sadly not uncommon on mental health wards. It is hoped that this verdict will help prevent similar fatalities.” 

Victoria McNally, INQUEST caseworker working with the family said:

“The inquest heard that part of the reason for the closure of the Noel Lavin Unit was the concern surrounding the circumstances of Sarah’s death. In INQUEST’s experience this failure is not unusual and urgent action is needed to ensure the safety of detained patients.”

Notes to editors:

  1. The final inquest hearing took place over eight days  between 4 – 15 November 2013 before Deputy Coroner for Surrey, Miss Alison Hewitt sitting at Woking Civic Centre
  2. INQUEST has been working with Sarah Shepherd's family since her death in 2011. They are represented by INQUEST Lawyers Group members Danny Friedman QC and Tony Murphy of Bhatt Murphy
  3. The family ask for privacy to be allowed to grieve. Any requests for information should be directed to Tony Murphy at Bhatt Murphy solicitors