‘NHS mental health services failed my inspiring daughter – I don’t want other patients to suffer the same fate’

A mother whose daughter was found to have been neglected by a hospital before taking her own life has blamed the “failures of the system” for her daughter’s death and has demanded improved care for future patients.

Court documents show Iona Imogen Lee’s suicide is one of at least five deaths that failures at Derbyshire’s mental health units caused or contributed to in the past decade. The health and social care regulator is currently reviewing information over three deaths at the units.

Morag Lee opened up about her “inspiring, friendly, loved” daughter Iona’s heartbreaking final hours on the Hartington Unit at the Chesterfield Royal Hospital in Chesterfield, before the 24-year-old was transferred to the ICU where she died on 18 September 2023.

The 57-year-old mother, from Derby, spoke to The Independent after a coroner ruled in January that her child had died by “suicide contributed to by neglect” on the ward where she had been detained under the Mental Health Act on 15 September 2023.

It was found at the inquest into Iona’s death in January that “there were a series of errors in the planning, management and implementation of Iona's observations after admission” and that “instruction, information and supervision were all inadequate, as was the primary induction”.

The jury concluded that Iona’s observation level should have been raised to being kept within staff’s eyesight, but due to staff shortages on the ward, she was only being checked intermittently. Even then, this should have been at least every 15 minutes, but the 24-year-old was not found until 43 minutes after she was last seen.

MS Lee raised “serious concerns” about the management of the Hartington Unit and believes blame also lies with this and previous governments in their role overseeing a crippled NHS.

Inquests over the last 10 years identified failures by the Hartington and Radbourne Units that caused or contributed to at least five deaths, including over incorrect decisions around patients being granted leave or discharged from the wards, wrongful prescription of medications, and inadequate risk assessment. In a report, coroner issued a warning to the Trust asking for policy change for fear of risking future deaths.

Calling for change for future patients, Ms Lee said: “In the past year, the hospital have changed their policies, but guidance was in place two years ago that wasn’t followed and led to my daughter’s death – so how do we know that what’s in place now will continue being implemented? What reassurances does the public have?”

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Source: The Independent, 13 April 2025