Clinical Negligence & Catastrophic Injury Solicitors
Tragic death of young mental health patient.
The parents of a woman who took her own life at a mental health hospital claim that failings in her care were "unbelievable.”
Claire Greaves, 25, from Pontypool, died when she was a patient at Cygnet Hospital, Coventry in February 2018.
She was a mental health campaigner and writer who had suffered with anorexia and a personality disorder from an early age.
In May 2017, she was moved from Abergavenny's Nevill Hall Hospital to Cygnet. At the time she tweeted: "I wish I could just go home, I don't want to be over 100 miles away from home for such a long time."
Her parents Colin and Debbie Greaves said they were told it was the only available hospital that could manage both of Claire's conditions and were "reasonably positive."
But they soon had concerns about staffing levels and a lack of access to therapies.
Then their daughter was placed in "seclusion and long-term segregation" and her parents were told they could not contact her for several weeks.
After a phone call in January 2018, Mr Greaves said: "She told us that she had no furniture in the room, that her mattress was brought in at night for her to sleep on and then taken back out.
"She also mentioned that there had been poor support for her hygiene whilst she was in there."
Her parents were trying to get her moved to a hospital nearer to their home when she died.
An inquest jury reached an "open" conclusion, and did not decide it was suicide.
Claire Greaves had been assessed as being at high risk of self-harm or suicide between 17:00 and 18:00 each day but she was able to obtain a piece of fabric left on the floor outside her room and used it to kill herself alone in her room.
The inquest jury found several failings including that long-term segregation and seclusion contributed to a decline in the young woman’s mental state; staffing levels "probably caused, or contributed," to her death and that there was a failure to increase observations despite her making numerous self-harm attempts in the days leading to her death.
Other failings highlighted by the jury included that if there been "sufficient staff" then Claire Greaves’ care plan could have been followed and the risk period of 17:00 to 18:00 "would have been covered". The jury also added that there was a failure in allowing the young woman to be on her own in her room prior to her death, contrary to her care plan.
Mr Greaves said he felt "numb" when he heard the conclusions, adding: "It seems unbelievable that they can miss ward rounds and can make changes without doing the proper risk assessments and cannot follow care plans. The failings were quite shocking."
He said he believed at first that the move to Cygnet would help his daughter but the fact it did not meant he now felt guilt as well as loss.
The Care Quality Commission (CQC) had already raised concerns about Cygnet before Claire Greaves’ death.
The CQC found recruitment and retention of staff was difficult with a high turnover that led to a shortfall in training and supervision levels. This lack of consistency led to some patients feeling unsafe on the wards, the CQC said.
Another CQC inspection published five months after Claire Greaves death found staffing was still a problem, with 61% of employees not comfortable with their daily workload.
In its own investigation into the death, Cygnet concluded the root cause was the young woman’s ability to "access material from another service user at a point when this was not seen by staff and was then able to ligate with it."
The report also stated days before her death there was a reduction in her "observation levels", for which the reason was unclear.
Her parents said they have not received an apology, or any communication from Cygnet, since the inquest.
The company said: "We were deeply saddened by Claire Greaves death in February 2018 and we continue to extend our sincere sympathies to her family. Cygnet co-operated fully with the investigation into the circumstances surrounding the death and we noted the recommendations made during the inquest.
"We have already implemented a number of measures to address the key learnings from this and we will ensure that we comply fully with all of the recommendations made."
A spokesman for Aneurin Bevan University Health Board also offered condolences to the family.
He said: "We have undertaken a full review of the board's role in commissioning Ms Greaves' placement at Cygnet Hospital and are currently implementing a number of recommendations to review placements for individuals with complex needs."