Another death of a 'gifted' young woman... another urgent call for change

Amina Ismail dreamt of becoming a nurse or paramedic. Driven by compassion, she wanted to help others. But her life was tragically cut short when, aged just 20, she was found unresponsive in her bedroom on a psychiatric ward.

It's another heartbreaking story of a young woman battling mental ill-health... another promising future shattered. Like many others across Greater Manchester, she struggled hours away from home.

Amina died without her family by her side. She was more than two hours away from her loved ones, having spent over a year sectioned on a Psychiatric Intensive Care Unit (PICU).

Her death followed those of three other women at the Priory Hospital in Cheadle within two months in 2022.

A senior coroner has since written to health secretary Victoria Atkins to outline concerns about the mental health system, warning: "Unless something is different, there are going to be more deaths of our young people."

Here, James Holt looks back at the tragic case of Amina Ismail...

READ MORE: 'Things need to happen or there will be more deaths'

Following a three-week inquest, a jury returned a 'misadventure' conclusion in the case of 'gifted' Amina, who died of 'ligature strangulation' last September.

Originally from Balsall Heath, Birmingham, she had been known to mental health services since she was 15. Following a number of placements, she was detained at the privately-owned Priory Group hospital in the Stockport village under the Mental Health Act in August 2022 - a year and a month before she would lose her life.

Miles away from home, as an out-of-area patient, Amina found day-to-day life challenging, according to her grieving father Ahmed. He said the year before her death was a 'real struggle' and that her placement at the Priory made her feel 'isolated'. All her family wanted was to bring her closer to home.

Amina Ismail was found fatally injured in her room on the Pankhurst Ward, a psychiatric intensive care unit (PICU), at Priory Hospital Cheadle Royal
Amina Ismail was found fatally injured in her room on the Pankhurst Ward, a psychiatric intensive care unit (PICU), at Priory Hospital Cheadle Royal -Credit:Irwin Mitchell

It was concluded that her length of Amina's stay at the clinic - as well as her deteriorating condition - contributed to her death. She had been deemed ready to be 'stepped down' in September 2022, but was 'subject to a prolonged stay on the PICU ward due to the shortage of appropriate specialist care beds', the inquest jury said.

Amina had been diagnosed with emotionally unstable personality disorder and post-traumatic stress disorder (PTSD). The court was told how her struggles first began when a police investigation was launched into historic abuse she had suffered as a child.

In the days leading to her death, Amina had been put on 'enhanced observations' following a self-harm incident. However, these were reduced to every 15 minutes, following a ward round meeting on September 13 - two days before the fatal incident.

After another ligature incident the day before her death, a jury was told that a discussion was held in relation to increasing her observations, but that it wasn't deemed necessary, and that other' risk management' measures were taken instead, including taking risky items out of her room.

It was the following day, September 15, that Amina was found fatally injured in her room on the Pankhurst Ward. Emergency services attended and continued resuscitation attempts which had been commenced by staff, but she was pronounced dead shortly afterwards.

The Priory Group's Cheadle Royal Hospital
The Priory Group's Cheadle Royal Hospital -Credit:MEN Media

Presiding over the case, coroner Andrew Bridgman said he would write to the health secretary outlining his concerns about the current care system. He admitted this was 'not the first time' he had to write such a letter, adding he had written a similar warning to the government eight-months-ago.

Serious concerns were raised by coroners after the deaths of three other women in 2022 at the Priory.

The Manchester Evening News reported in December how the coroner had written a 'prevention of future deaths' letter to the government concerning Lauren Bridges, 20, from Bournemouth.

The a 'straight-A student' who dreamed of becoming a doctor or nurse had also been at The Priory's Cheadle Royal Hospital for over five months when she was found unconscious in her en-suite bathroom on February 24, 2022. The jury in that inquest also noted her 'prolonged' stay at The Priory.

Beth Matthews, originally from Cornwall, was a blogger with a 'massive' online following. An inquest concluded neglect by staff at the hospital contributed to her death by suicide. She died on March 21, 2022 after ingesting a poisonous substance she ordered online that she told staff was protein powder.

Beth Matthews
Lauren Bridges

After, the Priory said acknowledged that 'far greater attention should have been given to Beth's care plan' and that 'immediate steps' were taken 'to address the issues around how we document risk and communicate patients’ care plans, alongside our processes for receiving and opening post.'

Just weeks before, on January 23, Deseree Fitzpatrick, another patient at the Cheadle Royal Hospital, died after being found unresponsive in her room. She had been admitted just days before due to risks of self-harm and for alcohol detoxification.

Deseree Fitzpatrick
Beth Matthews -Credit:Leigh Day solicitors

The 30-year-old had been living in sheltered accommodation after being the victim of domestic violence and was diagnosed with Emotional Unstable Personal Disorder (EUPD). Deseree was taking a number of medications from her GP, but was then prescribed a number of additional drugs, the majority of which had a central nervous depressant effect.

The inquest before Mr Bridgeman found she had choked in her sleep after being given inappropriate medication which had caused 'significant sedation'. The coroner said there was insufficient consideration of 'polypharmacy' and that the medication regime was inappropriate.

The inquest also heard there were missed opportunities for a review of that regime and that she was given so much medication that it resulted in profound sedation and the loss of her gag reflex. The Priory apologised following Deseree's death.

Following the conclusion of the inquest into the death of Amina, Mr Bridgman told jurors he intended to write another 'prevention of future deaths' report, this time touching the national picture in care.

"Things need to happen. I cannot say what needs to happen. I simply point out that unless something is different there are going to be more deaths of our young people," he said.

Amina's family and their legal team are now calling for action to tackle 'a national shortage of appropriate placements to help young people, particularly women, with complex mental health needs'.

Amina's father Ahmed, speaking on behalf of himself and Amina's mother Roda, said in a statement: "Amina was a wonderful daughter and sister. She was very gifted and had ambitions of becoming a nurse or a paramedic. She also enjoyed art, especially painting.

Amina Ismail died aged 20 at Cheadle Royal Hospital
Deseree Fitzpatrick -Credit:Ison Harrison Solicitors

"The last year was a real struggle for Amina. She was miles away from home and despite us visiting and supporting her as much as we could, we felt she was isolated. All we desperately wanted was to at least to get her closer to home and then back to her family.

"It’s almost impossible to describe the hurt and pain we’re going through following Amina’s death. She had her whole life ahead of her and it devastates us that she’s no longer with us and she’ll never get to fulfil her potential and ambitions.

"It’s a reflection of our mental health system that Amina was in and out of placements and moved from pillar to post for years, while we feel, never really getting the help and support she needed. If she had then we wouldn’t have had to go through the trauma of losing her and the trauma of trying to establish answers in her memory.

"All we can hope for now is that lessons are learned from how Amina was let down. It’s imperative that changes are made to how people with mental illnesses, and particularly young women, are cared for. The current system isn’t equipped to deal with our most vulnerable and has to change for the better.”

A Priory spokesperson said: "We would like to again convey our sincere condolences to Amina’s family following her tragic death and our thoughts remain with them at this difficult time. Following Amina’s death we completed a comprehensive investigation and have implemented all the actions.

"Despite the best efforts of our staff to ensure Amina’s discharge at the earliest opportunity, this proved very challenging to arrange due to the complexities of care Amina needed and limited specialist bed availability. As the coroner has highlighted, more work is required nationally to ensure patients do not experience prolonged stays in psychiatric intensive care units and we will continue to support our NHS partners and commissioners in their efforts to address this."