Inquest concludes into the self-inflicted death of 23-year-old Lauren Finch who tragically died as a result of suicide whilst an inpatient at Westleigh Unit, Atherleigh Park.

Before HM Assistant Coroner Rachel Galloway
Bolton Coroner’s Court, Paderborn House, Howell Croft North, Bolton, BL1 1QY

Tuesday 1 October – Friday 11 October 2019, lasting 8 days.

Lauren was tragically found hanging in her room at Atherleigh Park on 17 September 2018.  She died 7 days later on 24 September at the Royal Bolton Hospital, at the age of 23.

The jury concluded that Lauren had died as a result of suicide and left a number of critical findings. They found the following factors probably contributed to Lauren’s death:

• The risk of suicide on the 16/17 September were not properly assessed.
• Observations levels on the 17 September were not correct.
• The circumstances of Lauren absconding from Westleigh Ward on the 16th which  led to:
  • an impact on Lauren’s state of mind following the police involvement in Lilford Park on 16th September.
  • Lack of suicide risk review at Atherleigh Park.

And the following factors possibly contributed to Lauren’s death:

• The cycle of admissions and discharges from hospital.
• Quality of the observations.
• The lack of risk assessment of suicide and self-harm.
• Failure of the anti-barricade system, all at Atherleigh Park.

There was a delay in accessing Dialectical Behavioural Therapy (DBT) treatment for Lauren but this did not contribute to her death.

Lauren was a kind, beautiful girl, who had lots of friends and a love of animals that inspired her to begin studying to become a veterinary nurse. The inquest heard that Lauren’s mental health began deteriorating while in high school and was eventually diagnosed with ‘Emotional Unstable Personality disorder’ (EUPD) and clinical depression.

The jury heard that between March and September 2018, Lauren had six admissions into Atherleigh Park, ranging between 4 and 53 days. Over this period, evidence was heard that there was an escalation in Lauren’s self-harm and suicide attempts. This included several incidents of cutting which required hospital treatment, overdoses, running into fast moving traffic and attempts to jump off a bridge and multi-storey car park.

On the 14 September 2018, Lauren was detained under section 2 of the Mental Health Act at Atherleigh Park for the final time. Lauren had been admitted following a missing person search after self-harming. The inquest heard that whilst on the ward it was recorded that Lauren attempted to ligature on two occasions, attempted to abscond from the ward twice and attempted to take medication from the medication trolley.

On the 16 September 2018, Lauren was able to abscond from the ward by following a doctor through a door. The jury heard that Lauren was restrained by GMP and returned to the ward.   The jury were shown photographs of the bruising Lauren said she had received as a result of this restraint. They heard that Lauren had been in pain and was upset following the incident and that she had reported that the Police had laughed at her and called her a “silly little girl”.

Despite the incidents on the 16 September, the inquest heard that while Lauren was asleep on the morning of 17 September, her observations were downgraded from every 10 minutes to every 30 minutes. It was also heard that this decision was made without awareness of all the incidents that had taken place over the weekend and without review of the records.

Evidence was heard that Lauren isolated herself on the 17 September and was noted to be tearful. She was last seen on the ward at around 21.05pm.  At approximately 21.20pm, ward staff noticed a sheet over Lauren’s door and attempted to enter her room. The jury heard that staff had difficulty entering Lauren’s room due to issue with the anti-barricade door. Lauren was found having ligatured in her room and an ambulance was called for assistance. The inquest heard that staff were not present to meet the paramedics upon arrival at the hospital site to direct them to the ward.

At the inquest, North West Boroughs NHS Trust made a number of admissions about failures and shortfalls in the care they provided to Lauren. HM Assistant Coroner Ms Rachel Galloway announced her intention to make a Prevention of Future Deaths Report in respect of the implementation of the observation policy and record keeping.

Lauren’s family said:

Firstly, we are thankful to the Coroner and Jurors for finally giving our family the answers we have sought for over the last 12 months.

We are able to say with great disappointment that the services that we entrusted to look after our precious Lauren and which also look after so many other vulnerable people in the borough have admitted to and have been found to have significant failures in their line of care.

We hope that this inquest will prevent further deaths in the future and that no other family will have to endure the pain and suffering we have. 

Alice Stevens of Broudie Jackson Canter Solicitors said:

This inquest has highlighted clear failures in the care afforded to Lauren in the lead up to her death.  Lauren’s family believed that she would be safe in Westleigh Unit, yet she was able to abscond from the ward on multiple occasions and was ultimately able to take her own life.  I hope that the Trust take the Coroner’s Prevention of future Deaths Report very seriously and take steps to ensure that changes are made.

Deborah Coles, Director of INQUEST said:

All the warning signs were there, but Lauren was failed not only by mental health services but the police, both of whom had a responsibility to keep her safe. The serious risks of restraint on people with mental ill health are well recognised. The jury highlighted the traumatising impact of Lauren’s interaction with the police as a contributory factor in her death.

We are seeing repeated patterns of failure, ill treatment and neglect in the care of women in secure mental health settings. These are hospitals where women should be safe and their human rights protected. There is clearly a gulf between addressing the needs of women like Lauren, and the resources provided to care for them. To prevent future deaths it is essential that specialist, trauma-informed and women-centred treatment is available.

The family is represented by INQUEST Lawyers Group members Alice Stevens and Lauren Bailey of Broudie Jackson Canter Solicitors and Kate Stone of Garden Court North Chambers.

For information and advice on how to safely report on self-inflicted deaths, please look at the Samaritans Media Guidelines for reporting suicide and self-harm.