"Things need to happen or there will be more deaths" - Inquest finds 'misadventure' led to woman's death at Priory unit

A coroner has vowed to write to the health secretary because 'things need to happen' following the concerning death of a woman at a mental health unit.

Assistant Coroner Andrew Bridgman spoke out and said he would be issuing a report about a worrying national picture in mental health care after a jury returned a 'misadventure' verdict over the death of Amina Ismail, 20, who they concluded died of 'ligature strangulation'. She went into cardiac arrest, the inquest has heard.

Amina, 20, was found collapsed in her room on the Pankhurst Ward, a locked psychiatric intensive care unit (PICU), at the Priory's Cheadle Royal Hospital, Stockport, on September 15 last year. Emergency services attended and continued resuscitation attempts which had been commenced by staff, but she was pronounced dead shortly after.

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Amina, originally from Birmingham, had been taken in as an out-of-area patient in the privately-owned hospital under the Mental Health Act since August 2022, some 13 months before she died. She had been diagnosed with emotionally unstable personality disorder and post-traumatic stress disorder (PTSD). The court was previously told how her struggles began when a police investigation was launched into historic abuse she had suffered as a child.

Following a three-week inquest at Stockport Coroners' Court, today (Thursday) jurors recorded a 'misadventure' verdict, noting that Amina's length of stay at the clinic and deteriorating condition had contributed to her death.

Jurors also heard that a health assistant had not followed policy, although that was not found to have contributed to Amina's death.

They concluded: "Amina was ready for step down in September 2022, but was subject to a prolonged stay on the PICU ward due to the shortage of appropriate specialist care beds. Amina's mental health deteriorated during her long PICU stay. These factors contributed to the circumstances of Amina's death.

"The (healthcare assistant) did not follow the Priory policy at 15.35hrs when she did not enter Amina's en-suite after calling her name. Instead she returned at 15.36hrs and entered the en-suite. This one-minute delay did not contribute to the circumstances of Amina's death."

Assistant Coroner Bridgman thanked the jurors for their deliberations and told them he would be writing a letter 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.

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. She was rushed to Wythenshawe Hospital with her family making the six-hour journey from Dorset to be with her. A clinical decision was made, in consultation with Lauren's mother Lindsey, and her loved ones, to end her life support and she died two days later.

The jury in that inquest noted her 'prolonged' stay at The Priory.

Following the latest inquest, Mr Bridgman told the jurors he intended to write another 'prevention of future deaths' report, this time touching the national picture in care, adding: "Because 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."

Amina's inquest heard earlier evidence from Dr Jasmeet Soar, an A&E consultant with expertise in cardiac arrest, brain injury and resuscitation, was heard. Dr Soar said CCTV showed there was a gap of 15 minutes from when Amina was seen walking into her bedroom to when she was found unconscious. He said that the 15 minute window would have been 'sufficient time' for her to apply a ligature and suffer a cardiac arrest.

The medic told the court a 'reasonable estimate' from application of a ligature to cardiac arrest was 15 minutes and that in Amina's case it was likely around five minutes.

The inquest heard on Tuesday (May 7) Amina had been put on 'enhanced observations' following a self-harm incident on September 9 or 10. She was on constant, one-to-one observations. But those observations were reduced to every 15 minutes following a ward meeting on September 13, two days before her death.

Dr Soar said looking at the CCTV and from reading witness statements, Amina was found 'unresponsive and not breathing' by health workers at 3.36pm on September 15 and that the ligature was 'removed very quickly'.

He said the ligature was removed in a 'reasonable time', but that once it was off, there was a 'delay' in starting chest compressions. Dr Soar said guidance states CPR should be started within 10 seconds of finding someone unresponsive, but that judging from the CCTV, CPR only started once a doctor arrived and there was a delay of 'one to two minutes'.

Dr Soar said there may have also been a delay in calling an ambulance but that it was 'difficult to say' as he was relying on witness statements. He said there should have been several people working in parallel, with one person caring for Amina and another calling an ambulance. He later added that records showed all the staff involved in the response had up to date training.

Dr Soar said ambulance crews arrived 10 to 12 minutes later and were unable to start Amina's heart, which he said suggested she had been in cardiac arrest for 'a while' and there was 'no reasonable chance of survival at that point'. CPR was stopped at 4.26pm, the inquest heard.

Asked by assistant coroner Andrew Bridgman whether a one to two minute delay in starting CPR, or the delay in calling the ambulance, would have had an effect on the outcome, he said the delays 'did not make a significant contribution to Amina's death' based on his opinion that she was already in cardiac arrest.

He later said there was 'no realistic prospect of survival' if she was in cardiac arrest when discovered. Asked whether the delays made 'more than a minimal contribution' he replied: "No."

Dr Soar added that it was possible if Amina's heart had been restarted it would have led to hospital admission, but would not have led to survival as it would not have reversed the unsurvivable brain injury she would have suffered from the ligature incident.

He said it was not uncommon for patients that have suffered a ligature incident to have their heart restarted, but to then die in hospital once their life support is turned off. He added that an 'advantage' of that scenario would be to allow loved ones to be by a patient's bedside.

Dr Soar was also questioned by coroner Mr Bridgman on the 'ligature event' on September 14, the day before Amina's death. She never lost consciousness during the incident and did not need to go to hospital, the inquest was told.

The jury previously heard from mental health nurse and deputy ward Manager Igor Danchenko, who was one of the staff who responded to the incident on September 14.

Mr Danchenko said following the incident a discussion was held in relation to increasing Amina's 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.

Barrister Kate Stone, representing the family, previously read to the inquest notes of an interview with nurse Lois Henry, who Mr Danchenko handed over to on the evening of September 14, as part of the Priory's internal investigation into the incident.

They read: "On the day before Amina's death, they (the night staff) were told by the Deputy Ward Manager Igor that putting her on higher observations is the last thing they should do.' Ms Henry said he went on to comment that 'it was the nature of the job that people like her will die through misadventure."

The notes added that Ms Henry had said that Mr Danchenko had told her that Amina was 'pretending to be out of it and closing her eyes' and that 'Lois feels the clear message was Amina was faking it'.

Mr Danchenko said he did not recall making that 'specific statement during the course of the handover' or using that 'specific language'.

After the inquest, a hospital 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."