Before HM Senior Coroner Grahame Short Central and Southampton & New Forest Coroners Court
The inquest into the self-inflicted death of Ellie Brabant has concluded, with the coroner finding that the lack of a clear care plan, and the decision to discharge Ellie from Section 3 of the Mental Health Act more than minimally contributed to her death. Her family were represented by Sarah Hemingway of the Garden Court Chambers Civil Liberties Team.
Ellie, 28, was found hanging whilst an inpatient at Antelope House, a mental health unit in Southampton on 2 November 2017. She died three days later on 5 November 2017.
The inquest heard Ellie may have suffered serious sexual and physical abuse from a young age by members of the public, although no prosecutions have been brought, and began to self-harm from the age of 11. She had a diagnosis of Emotionally Unstable Personality Disorder and had spent most of her adult life detained under Section 3 of the Mental Health Act.
In the months leading up to her death, Ellie was moved five times and spent time in a Psychiatric Intensive Care Unit due to escalating self-harm. Within nine days of residing in Antelope House, Ellie was made a voluntary inpatient. She subsequently utilised regular leave from hospital during which she reported being raped and taking drugs.
On the night of 1 November 2017, Ellie disclosed this to staff. She also stated that she had ‘had enough of living’. This information was passed to staff in a handover note, which was only provided to the coroner on the final day of evidence at the inquest. The inquest heard from a psychiatric expert that there were a number of opportunities for Ellie’s status as a voluntary inpatient to be reviewed, however, despite her escalating self-harm she remained a voluntary inpatient until her death.
At 12.45am on 2 November 2017, whilst an informal check on Ellie was being made, she was found to be choking having swallowed an item. Staff managed to dislodge the item, but then left her alone in her room only increasing her observations to once every 15 minutes. Approximately 10 minutes after this serious self-harm attempt, Ellie was found hanging.
A Prevention of Future Death report will be written by the coroner in relation to the following matters:
- Staff training around the importance of, and implementation, of observations of patients;
- Safeguarding of patients at risk of crimes and reporting these to police. The coroner noted that vulnerable patients like Ellie need to be safeguarded and further training on informal patients are needed;
- Training should be extended to powers to restrict voluntary patients’ leave under the Mental Health Act; and
- Clear guidance and training is needed in relation to involving families when patient consent is withdrawn.
The coroner has also written to Southern Health Trust in relation to their conduct, including concerns about the preservation of evidence following serious incidents and late disclosure of evidence at the inquest.
Ellie’s family said: “We are devastated by Ellie’s death and the failures in her care at Antelope House. We were not given the opportunity to feed into Ellie’s care and were instead left to watch her rapid decline. The Ellie who took her own life was not the Ellie we knew. Although we accept procedural changes have been made following Ellie’s death, we do not believe these changes address the fundamental deficiency in Ellie’s care. We do not feel confident that should another patient like Ellie be under Southern Health’s care, anything would be done differently. We are grateful to the coroner for completing a Prevention of Future Death Report and hope that it will force the Trust to take the matters highlighted in Ellie’s inquest seriously.”
Deborah Coles, Director of INQUEST said: “These stark failings are sadly familiar and point to a systemic problem in how extremely vulnerable women in mental health settings are looked after.
There is a clear link between the trauma of rape and mental ill health. That staff did not respond to this information with immediate action and care is staggering. Too many victims of sexual violence are failed by statutory agencies. These failings are indefensible and are costing lives.
Once again, the conduct of Southern Health Trust suggests a greater concern about reputational management, rather than the opportunity to identify where they have failed to keep people safe.”
Alice Stevens, Solicitor at Broudie Jackson Canter Solicitors, said: “This is a deeply disturbing case. Ellie was a vulnerable patient with complex needs who was not afforded proper care and attention by those responsible for her care. The inquest was a frustrating process for Ellie’s family with Trust staff disagreeing with independent experts who were highly critical of the care afforded to Ellie.
I also have concerns about the way the inquest process was handled by Southern Health given that they admitted Ellie’s room had been cleaned prior the police arriving to complete their investigation and that key evidence was only provided on the final day of the inquest. I am glad that the coroner has taken these matters seriously and hope that his letter to the Trust and Prevention of Future Death Report are given serious consideration by the Trust.”
The inquest has been covered in the media, including BBC news.