“I she thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental hospital in Milton Keynes.
Eight weeks later, Brooke took her own life.
“I thought that she would be well cared for, that she would recover and be able to move on with her life. I can’t get over that,” Darbon said.
The inquest jury concluded that Brooke’s death could have been prevented and that the private health care provider Elysium Healthcare, which ran the hospital, failed to adequately manage her suicide risk. It also found that serious failures in risk assessment, communication, and setting watch levels contributed to her death. Elysium agreed that if she had been placed on 24-hour observations, Brooke would not have died.
Brooke, who was autistic, wanted to be a veterinarian. Darbon remembers her as “very loving, attentive and sensitive.” But she was worried too. She had a history of self-harm and suicide and had been in the care of NHS child and adolescent mental health services at the age of 12.
In 2018, she was repeatedly isolated under the Mental Health Act due to her increasing suicide attempts and self-harm. After a period in an NHS facility in Surrey, she moved to Chadwick Lodge, which specializes in the treatment of personality disorders.
After a few weeks there, Brooke was doing well and the staff was pleased with her progress. She was due to move to Hope House, a separate unit in the hospital, to begin more specialized therapy for emotionally unstable personality disorder, and she was eager to make the move.
But then the teen’s mental health deteriorated again. On June 5, 2019, he attempted suicide. Five days later, she was seen twice that night secretly manipulating possible ligatures, but no appropriate action was taken. A few minutes later she was found unconscious in her room. She received CPR but died the next day at Milton Keynes University Hospital.
After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner on the investigation, took the unusual step of issuing a Notice of Prevention of Future Deaths, a legal warning detailing the changes that must be made. to stop other people. dying under the same circumstances. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge.
It set out the detailed criticisms the jury had made of Elysium’s interaction with Brooke after her attempted suicide on June 5. They cited the hospital’s failure to communicate information about Brooke’s suicide attempt, to search her room after she was found to be tampering with possible ligatures the night she died, and to place Brooke under constant observation after her death. .
“[Handling potential ligatures] would have and should have resulted in a full risk assessment and search of his room, that would have resulted in an increase in his level of observations to 1:1 observations,” the jury concluded. “Brooke Martin, had she been constantly observed or had other safety measures been in place, she would not have been able to tie the ligature that caused her death and therefore she would not have died on June 11, 2019.”
Paul Martin, Brooke’s grandfather, said: “What happened was such a fundamental mistake, negligence, that it defies logic. How can a company that is supposed to take care of vulnerable people be so negligent?
Brooke is not the only hospitalized patient to die at an Elysium mental health facility. The charity Inquest represents six other families with loved ones who have died since 2016 while in her care.
The investigation in death of Nadia Shah, aged 16 at an Elysium unit in Hertfordshire in 2019 found similar flaws to those in Brooke’s case: delayed observation and access to ligatures, a dangerous combination. Nadia’s death was due to a “misadventure, contributed to by inadequate care at the Potters Bar clinic,” the jury said.
Elysium Healthcare said it had sent its deepest condolences to Brooke’s family and friends for “this tragic incident”. She reiterated what she said when she concluded the investigation last July, that after her death she immediately took “significant steps” to improve patient safety at Chadwick Lodge.
He also pledged to reflect and “implement where necessary…further learning as a result of the research… [to] ensure that our policies and procedures are as effective and responsive as possible in providing care to highly vulnerable people.”
