10 April 2024

Before HM Assistant Coroner Tina Harrington
Essex Coroner’s Court
2 April 2024 – 9 April 2024

Sophie Alderman died on 19 August 2022, aged 27, whilst under the care of Essex Partnership University NHS Foundation Trust (EPUT), having applied a ligature in her bedroom while a detained inpatient at Willow Ward, Rochford Hospital, Essex.

Sophie’s family describe her as a wonderful person with a massive heart, who brought massive positivity with her, and is sorely missed by her loved ones. 

Sophie had a long history of serious mental ill health and self-harm, first having come into contact with mental health services at the age of 14. She experienced multiple mental health inpatient admissions, and received community mental health support from her teens onwards. 

Her family describe Sophie’s mental health experiencing “peaks and drops”. By the time of her final admission to hospital, she had been diagnosed with Emotionally Unstable Personality Disorder (EUPD), Schizoaffective Disorder, and Post-Traumatic Stress Disorder (PTSD). 

On 30 April 2022, Sophie came under the care of EPUT when she was admitted for assessment at Basildon Mental Health Unit on 30 April 2022. Despite an initial plan to transfer her to a mental health hospital for treatment, Sophie was subsequently discharged from Basildon 6 weeks later on 15 June 2022. 

The jury heard evidence that shortly after her discharge, concerns were raised about Sophie’s declining mental state, including her increased paranoid and suicidal ideation. She was detained again just a week later on 26 June 2022, and transferred to Willow Ward, Rochford Hospital, on 14 June 2022. 

Weeks before Sophie’s admission to Willow Ward, an undercover documentary reporter for Channel 4 filmed shocking footage of poor care, and abuse of other patients under the care of EPUT on that ward. This was later broadcast in  ‘Hospital Undercover Are They Safe? Dispatches’.

Sophie spent just over a month on Willow Ward. During that time, the jury heard evidence that she continued to present with psychotic delusions and hallucinations. 

Due to paranoid ideation around her medication, Sophie repeatedly required restraint for this to be administered. Despite this, her responsible clinician considered she was “compliant” with her medication and evidence was heard that Sophie’s compliance was a factor in his decision to lower her observations from constant within eyesight to six times an hour. On 16 August, the clinician subsequently reduced Sophie’s observations to hourly.

On 19 August, the jury heard that Sophie was involved in an altercation with another patient, sustaining an injury to her foot which required assessment by the duty doctor. 

Sophie subsequently requested a 1:1 session with a member of staff, but the staff member in question was unable to provide this as she was required to respond to another incident.

Giving evidence, the ward manager acknowledged that there may have sometimes been a link between the high level of restraints on the ward at the time, and the high reliance on bank and agency staff, some of whom may not be experienced enough in de-escalating. 

The jury heard evidence that five restraints took place on the ward during the afternoon of 19 August, and that there were only two qualified permanent mental health nurses on the ward at that time, resulting in a heavy reliance on bank and agency staff to ensure that the ward was staffed for each shift.

Staff accepted in their oral evidence that the high incidence of restraint and incidents on the ward reduced the amount of time that they had to engage therapeutically with patients.

At around 17:20, staff attended Sophie’s room after she was heard and seen headbanging. The jury heard evidence that Sophie presented as distressed and highly agitated and told staff that she did not want to feel how she did. Police evidence later confirmed Sophie had an injury to her head consistent with headbanging. 

Sophie’s Responsible Clinician gave evidence that, although he was not on the ward at this time, he would have expected the duty doctor to be contacted at this stage. He added that had he been consulted, he would himself probably have raised Sophie’s observation levels in response to the headbanging, recognising this as risk-relevant behaviour. 

However, after only two minutes with Sophie, staff left her alone in her bedroom without formally assessing her or putting in place additional protective measures. They did not increase her observation levels or call the duty doctor.   

Sophie ligatured in her room only minutes after staff left. She was found unresponsive by staff at 17:35, by which time her condition was unsurvivable. 

The emergency response that ensued was marked by multiple delays. EPUT’s own Patient Safety Incident Investigation report described it as “confused and disorganised”. Sophie was sadly declared dead at 18:25 that evening. 

The Coroner determined there was sufficient evidence for the jury to decide whether the following issues probably or possibly contributed to Sophie’s death:

1. The decision to downgrade Sophie’s observations to Level 1 on 16 August 2022; and
2. The response to Sophie being found headbanging on 19 August 2022.

The jury concluded that Sophie died by “misadventure”. Sophie’s family were disappointed that despite being directed to return either a narrative conclusion, or a short form conclusion with a narrative, the jury returned only a short form conclusion and did not give any context, or exploration of the wider circumstances of Sophie’s death.

Tammy Smith, Sophie Alderman’s mother, said: “While I am surprised and disappointed by the brevity of the jury’s conclusions, it was clear to me throughout the evidence that my daughter was failed by Willow Ward. What is most concerning to me is the lack of accountability from EPUT throughout this process.

I wish that I could be confident that Sophie’s death would lead to real learning that would keep other families from experiencing the same tragedy, but to learn from an event, the first step is acknowledge where things went wrong, which throughout this process the Trust and its staff have failed meaningfully to do.

There are not enough words to convey my gratitude to Rachel Harger, Laura Profumo, Khariya Ali and Angel Dim. Without their amazing level of support and professionalism we could not have navigated this process.

Selen Cavcav from INQUEST has also played a very important part in supporting us.”

Selen Cavcav, Caseworker at INQUEST, said: “What this inquest revealed is a mental unit which is chaotic and unable to keep vulnerable patients safe let alone provide therapeutic care to help support their recovery.  How many more deaths is it going to take to make real changes by Essex mental health services? How many more lives cut short?

The short conclusion of this inquest and absence of criticism takes nothing away from the fact that Sophie's death could have and should have been prevented.”

ENDS

NOTES TO EDITORS

For further information, please contact Leila Hagmann on [email protected]

The family are represented by INQUEST Lawyers Group members Rachel Harger and Khariya Ali of Bindmans LLP and Laura Profumo of Doughty Street Chambers. The family are supported by INQUEST caseworker Selen Cavcav.

Other Interested person represented is Essex Partnership University NHS Trust (EPUT).

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

Deaths in Essex mental healthcare:

Since 2021, there is an ongoing inquiry into Essex Mental Health services. Following years of campaigning from bereaved families, the inquiry has now relaunched with statutory legal powers. See the Essex Mental Health Independent Inquiry website for the latest update. 

• Morgan-Rose  Hart, 18, died on 12 July 2022 after being found unresponsive on 6 July 2022 on Chelmer Ward at the Derwent Centre, an adult acute mental health ward in Essex. An inquest found that neglect contributed to her death. Media release.
• Marion Michel, 56, died of self-inflicted injuries on 4 March 2022 whilst an inpatient at Brockfield House, a secure mental health unit in Essex. An inquest found that the absence of a specific risk assessment may have contributed to her death. Media release.
• Chris Nota, 19, had been under the care of Essex mental health services when he died on 8 July 2020 after falling from a height in Southend. An inquest found that multiple failures in care contributed to his death. Media release.
• Edwige Nsilu, 20, died on 5 February 2020 after being found unresponsive at St Andrews Healthcare Essex. An inquest concluded that neglect contributed to her death. Media release.
• Darian Bankwala was 22 years old when he was discharged from EPUT mental health services at Rochford Hospital four months prior to his death on 27 December 2020. Darian had learning difficulties and some autistic traits which an inquest heard were never properly investigated or diagnosed. Media release.
• Bethany Lilley was 28 when she died whilst an informal patient on Thorpe Ward at Basildon Mental Health Unit on the evening of Wednesday 16 January 2019. The inquest in March 2022 concluded that her death was contributed to by neglect due to a plethora of failings by Essex University Partnership Trust. Media release.

Other relevant cases: Deaths of people in the care of Essex mental health services, November 2020

In 2021, EPUT was prosecuted in relation to health and safety failings concerning ligature points. The Trust was fined £1,500,000. Sentencing remarks.