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‘I thought she’d be safe’: a life lost to suicide in a place meant for recovery

"I 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 health hospital in Milton Keynes.

Eight weeks later, Brooke took her own life.

The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died.

In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders.

After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch.

But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital.

After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. 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 that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards.

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Source: The Guardian, 24 April 2022


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