February 21 2024
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Poor communication on mental health ward contributed to death of Claire Lilley

Poor communication on mental health ward contributed to death of Claire Lilley

Beyond the Wall, HMP Glenochil, Koestler Trust

The inquest into the death of a 38-year old woman detained under the Mental Health Act identified inadequate communication on a specialist mental health ward as a factor. Claire Lilley was detained at Oxleas House in Woolwich, South London, an adult ward providing 24-hour inpatient mental health services. Her mother had found her hanging in their home in Eltham in February 2019 and she died in hospital four days later.

Despite a psychologist’s assessment that Claire Lilley was at a high risk of suicide, she was permitted to go on authorised leave overnight. She experienced depression with psychosis and had previously been hospitalised in 2010 during a depressive episode. She had previously attempted suicide by overdose in October 2018, and she was subsequently detained under the Mental Health Act. She had been sectioned at Oxleas House from November 2018 till her death, though she had been authorised leave on two occasions prior to her death in February – this included overnight leave in December and unescorted leave in January.

Evidence given in the inquest confirmed that the woman’s delusional belief and risk of suicide was present throughout her time at the Oxleas Trust hospital. Moreover, in the two weeks prior to Claire’s suicide, Oxleas Trust did not actively seek feedback from her mother regarding how the leave at home was going. Claire’s mother also gave evidence in the inquest, and she stated that she had concerns about Claire’s worsening anxiety and mental state while on leave.

The only occasion where feedback was given in the two weeks leading to Claire’s death was when her mother brought her back from leave on 6 February as she was concerned about her daughter’s presentation and distress.

It was discovered in the inquest that there was no formulation of risk in Claire’s risk assessment. The risk assessment did not include Claire’s repeated disclosures to the clinical psychologist that she wished she died after the previous suicide attempt in October 2018. The psychologist’s assessment confirmed that Claire should not be left alone for prolonged periods of time and she was at a high risk of suicide – this was not in the risk assessment nor was it communicated to Claire’s mother. The risk assessment did not set out a risk management plan for Claire’s leave either despite the psychologist’s assessment and concern.

The jury found that there was a lack of consistent communication between staff at Oxleas Trust and Claire’s family prior to her death, and there was insufficient management cover to review risk and make decisions on this case.

‘I hope that her legacy will truly effect changes for other people, who sadly might find themselves in the same unfortunate situation,’ said Brigitte Fortin, Claire’s mother. ‘If there had been proper assessments, accurate reporting of events and meaningful engagement and discussions with her family, it would have helped her recovery and reduced the risks associated with her mental illness. Open communication involving her family and friends when on leave would have protected her life,’ she continued.

Jodie Anderson, INQUEST Caseworker said that ‘the failures in this case left Claire’s family without vital information and support, and left Claire without the professional healthcare she needed’.