Inquest concludes into the self-inflicted death of Ellie Brabant who tragically died as a result of suicide whilst the balance of her mind was disturbed, whilst an inpatient at Southern Health run, Antelope House

Before HM Senior coroner Grahame Short Central and Southampton & New Forest Coroners Court

Ellie was tragically found hanging in her room at Antelope House on 2 November 2017.  She died 3 days later on 5 November 2017 aged 28.

Senior Coroner Grahame Short concluded with a critical narrative this morning that the removal of Ellie’s Section 3 and that there was no clear care plan in place more than minimally contributed to her death. He ruled out gross failures and neglect. He also completed a Prevention of Future Death Report and has written to the Trust in relation to their conduct at the inquest. Ellie’s family consider that the failures in her care do amount to gross failures and are disappointed this was not recognised in the Coroner’s conclusion.

Ellie had a diagnosis of emotionally unstable personality disorder and had spent most of her adult life under Section in various hospitals. The inquest heard harrowing evidence that Ellie may have suffered sexual and physical abuse from the age of 13 from members of the public and began to self-harm from the age of 11. No prosecutions have ever brought in relation to this.

Ellie was detained under Section 3 of the Mental Health Act for 10 years of her life, during which time she attempted to take her own life on multiple occasions. In the months leading up to her death, Ellie was moved 5 times and spent time in a PICU due to her escalating self-harming behaviour.  She was moved to Antelope House in August 2017 despite both her and her parents expressing that it was not in Ellie’s best interests to move there due to negative past experiences in the Southampton area.

Within nine days of residing in Antelope House, Ellie was made a voluntary inpatient.  She subsequently utilised regular leave from hospital during which she reported being raped and taking drugs.  She also made a number of attempts to take her own life and expressed suicidal intent prior to being granted leave. On one occasion, she was detained by police under s.136 after a train had to make an emergency stop due to Ellie lying on the tracks.   The inquest heard from a psychiatric expert that there were a number of opportunities for Ellie’s status as a voluntary inpatient to be reviewed, however, despite her escalating self-harming behaviour she remained a voluntary inpatient until her death.

On the night of 1 November 2017, Ellie disclosed to staff that she has taken crack cocaine the previous two nights and had been raped. She stated that she had ‘had enough of living’.  The fact Ellie was ‘suicidal’ was passed to staff in a handover note, which was only provided to the Coroner on the final day of evidence at the inquest. However, the staff member responsible for the unit that night was not told Ellie was suicidal. 

At approximately 12.45am on 2 November 2017, whilst making an informal check of Ellie, she was found to have swallowed tissue and was choking. Staff managed to dislodge the tissue. Ellie, described in evidence as ‘quiet’ and not engaging, was then left alone in her room whilst staff decided to raise her observation levels to every 15 minutes. Health Quality Quest, who conducted an independent Root Cause Analysis following Ellie’s death, criticised this decision. The Coroner heard evidence that toilet tissue was removed from her room along with a scarf. However, at the inquest, the Trust disclosed that her room had been cleaned prior to the police attending.

Approximately 10 minutes later, Ellie was found to have ligatured with a scarf attached to her door. Staff attended and performed CPR, an ambulance was called and Ellie was taken to hospital. She remained in a coma for 3 days and brain stem death was recorded at 12.41 on 5 November 2018.

The Coroner concluded that:

• Ellie died as a result of suicide whilst the balance of her mind was impaired
• The decision to take her of Section 3 of the Mental Health Act more than minimally contributed to her death as it led to an escalation in her risk
• The lack of Care Plan in place more than minimally contributed to her death
• A Prevention of Future Death, Regulation 28 Report will be written in relation to the following matters:
  • Staff training in relation to the importance of and implementation of observations of patients;
  • Safeguarding of patients at risk of crimes and reporting these to police.  The Coroner noted that vulnerable patients like Ellie need to be safeguarded and further training on informal patients are needed;
  • Training should be extended to powers to restrict voluntary patients’ leave under the Mental Health Act; and
  • Clear guidance and training is needed in relation to involving families when patient consent is withdrawn.
• The Coroner has also written to the Trust in relation to late disclosure at the inquest and ensure the new documents are provided to the police.  He is also writing to them in relation to the concerns surrounding preservation of evidence following serious incidents such as this.

Ellie’s family said:  

“We are devastated by Ellie’s death and the failures in her care at Antelope House. We were not given the opportunity to feed into Ellie’s care and were instead left to watch her rapid decline. The Ellie who took her own life was not the Ellie we knew.  Although we accept procedural changes have been made following Ellie’s death, we do not believe these changes address the fundamental deficiency in Ellie’s care. We do not feel confident that should another patient like Ellie be under Southern Health’s care, anything would be done differently. We are grateful to the Coroner for completing a Prevention of Future Death Report and hope that it will force the Trust to take the matters highlighted in Ellie’s inquest seriously.”

Alice Stevens, Solicitor at Broudie Jackson Canter Solicitors, said:

  “This is a deeply disturbing case.  Ellie was a vulnerable patient with complex needs who was not afforded proper care and attention by those responsible for her care. The inquest was a frustrating process for Ellie’s family with Trust staff disagreeing with the HQQ and independent expert who were highly critical of the care afforded to Ellie. 

I also have concerns about the way the inquest process was handled by Southern Health given that they admitted Ellie’s room had been cleaned prior the police arriving to complete their investigation and that key evidence was only provided on the final day of the inquest. I am glad that the Coroner has taken these matters seriously and hope that his letter to the Trust and Prevention of Future Dearth Report is given serious consideration by the Trust.”

The family is represented by INQUEST Lawyers Group members Alice Stevens of Broudie Jackson Canter Solicitors and Sarah Hemingway of Garden Court Chambers.