A jury at the inquest of a “beautiful and kind” Wigan woman, who was found hanged in her room on a mental health ward, has found that several institutional failings contributed to her death.
Lauren Finch died in hospital in September last year, a week after being discovered suspended in her room at Atherleigh Park Mental Health Hospital.
The 23-year-old, the jury heard, began having problems with her mental health in high school and was eventually diagnosed with Emotional Unstable Personality disorder (EUPD) and clinical depression.
The jury heard the veterinary nursing student, who was described by her loved ones as “kind and beautiful”, was admitted to the facility six times between March and September for periods ranging between four and 53 days,
Evidence was heard that during this period, there was an escalation in Lauren’s self-harm and suicide attempts.
Three days before Lauren was found in her room, she was detained under Section 2 of the Mental Health Act at Atherleigh Park for the final time. She had been admitted following a missing person search after self-harming.
The inquest heard that while on the ward it was recorded that Lauren attempted to hang herself on two occasions, tried to abscond from the ward twice and also attempted to take drugs from the medication trolley.
On September 16, the day before she was found, Lauren was able to abscond from the ward by following a doctor through a door. The jury heard she was restrained by police and returned to the ward. They were shown pictures of the bruising she sustained.
The court heard Lauren had been in pain and was upset afterwards, claiming officers had laughed at her and called her a “silly little girl”.
Despite the incidents the day before, the inquest heard that while Lauren was asleep on the morning of September 17, her observations were downgraded from every 10 minutes to every 30 minutes.
It was also heard that this decision was made without awareness of all the incidents that had taken place over the weekend and without review of the records.
Evidence was heard that Lauren isolated herself that day and was noted to be tearful. She was last seen on the ward at around 9.05pm.
At around 9.20pm, staff noticed a sheet over Lauren’s door and tried to get into her room. The jury heard staff had difficulty entering due to issue with the anti-barricade door. Lauren was found hanging in her room and an ambulance was called but staff were not present to meet arriving paramedics to direct them to the ward.
The jury concluded that Lauren killed herself but that several factors probably contributed to her death. They concluded the risk of suicide on September 16 and 17 was not properly assessed and observation levels on September 17 were not correct and the circumstances of Lauren’s absconding from Westleigh Ward impacted on her state of mind after police involvement.
The jury also found a lack of suicide risk review at Atherleigh Park.
After the hearing, Lauren’s family said: “We are thankful to the coroner and jurors for finally giving us the answers we have sought for over the last 12 months.
“We are able to say with great disappointment that the services that we entrusted to look after our precious Lauren and which also look after so many other vulnerable people in the borough have admitted to and have been found to have significant failures in their line of care.
"We hope that this inquest will prevent further deaths in the future and that no other family will have to endure the pain and suffering we have.”
The family were represented by members of the Inquest Lawyers Group, Alice Stevens and Lauren Bailey of Broudie Jackson Canter Solicitors and Kate Stone of Garden Court North Chambers.
Ms Stevens said: “This inquest has highlighted clear failures in the care afforded to Lauren in the lead up to her death. Lauren’s family believed that she would be safe in Westleigh Unit, yet she was able to abscond from the ward on multiple occasions and was ultimately able to take her own life. I hope that the Trust take the Coroner’s Prevention of future Deaths Report very seriously and take steps to ensure that changes are made.”
At the inquest, North West Boroughs NHS Trust made a number of admissions about failures and shortfalls in the care they provided to Lauren.
John Heritage, its chief operating officer, said: “I would like to offer my sincere condolences to Lauren’s family.
“I appreciate it must be incredibly difficult to sit through a long inquest on top of losing someone you love.
“We know we made mistakes during Lauren’s care and have openly admitted these failings as part of the inquest process.
“We wholeheartedly apologise to Lauren’s family for these shortcomings and the understandable distress this has caused.
“A comprehensive investigation took place immediately after Lauren’s death and changes have been made to help minimise the risk of any similar incidents occurring in the future.
“We have strengthened our Observation, Safety and Engagement Procedure and over the coming months we are introducing an electronic system which will enable staff to use iPads to update records in real time as observations are carried out.”