A SENIOR coroner has criticised the treatment of a Southampton woman by a mental health trust following her death.

Eleanor Brabant, a patient at Southern Health NHS Foundation Trust's Antelope House facility in Southampton, was found hanging in her room on November 2 last year and died three days later at Southampton General Hospital.

Winchester Coroner's Court heard that opportunities to improve Ms Brabant's care were missed, someone had gone into Ms Brabant's room after she had been rushed to hospital, but before police had attended, and a "critical piece of information" was not given to officers.

It came as Southern Health's medical director Dr Karl Marlowe attended court to apologise directly to her family.

 

Dr Marlowe said: "Our staff work with the most vulnerable in society. I'm deeply sorry we were unable to keep Eleanor safe in our care."

The inquest heard that Ms Brabant had been detained under the Mental Health Act after years of mental health problems and drug misuse, but the decision was taken to release her in September 2017, meaning the 28-year-old, Winn Road, Portswood, would be a voluntary patient.

Senior Hampshire coroner Grahame Short criticised removing the legal detention, saying: "I find that this was a premature decision." Mr Short added an "adequate" care plan was not in place and this contributed to her death.

Recording a conclusion of 'suicide while the balance of her mind was disturbed', Mr Short added: "I accept Ellie (Ms Brabant) frequently changed her mind. Ellie was described as impulsive.

"It was a far from easy task (treating Ms Brabant) and I accept this case showed there was a range of clinical opinions.

"Ellie, I believe, need the security of well defined boundaries in her life."

Mr Short also said he would be sending a 'prevention of future deaths' report to Southern Health recommending changes at the trust, and would be making police aware about the existence of documents not previously given to them.

Following the inquest, Dr Karl Marlowe, on behalf of the trust, said: "This is a devastating time for Ellie’s family and I express to them my deepest condolences and those of all our staff. Whilst I cannot begin to imagine what Ellie’s family are experiencing, I sincerely hope this week’s inquest has provided more clarity and answers that will, in some small way, be helpful.

“Ellie’s family rightly expected their daughter to be safe in hospital and I am deeply sorry that we were unable to keep her from harm. Since Ellie’s death care at the hospital has been comprehensively reviewed, changes have been made and ongoing improvements are taking place. Some of these changes include: strengthening staffing numbers, leadership and teamwork; overhauling decision-making processes around safeguarding, and installing electronic sensors on bedroom doors to make the environment safer.

“Our mental health hospitals provide care for people experiencing an episode of severe mental health crisis. Due to the nature of their illness, some patients are at a very high risk of coming to harm. In this setting clinicians work extremely hard to care for people in a way that is both safe, and gives the greatest quality of life and chance of recovery.

“Whilst it is sadly not possible for any healthcare provider to completely eliminate all risks, and challenges undoubtedly remain, improvements are being made and we continue to work alongside our staff, patients and their families to make the hospital the safest it can possibly be.”