Mum haunted by daughter's final weeks on hospital ward

Mary Curran, pictured with her daughter Lily Lucas, who she said was "the absolute life and soul" of their family

The mother of a woman who died after being found unresponsive in a psychiatric hospital has said she is still haunted by her final weeks and that no-one has been held to account.

An inquest in 2024 found "gross failures" in the care provided to Lily Lucas, 28, at the privately-run Milton Ward at Cygnet Hospital in Kewstoke, Somerset. She died in September 2022 at Bristol Royal Infirmary from cardiac arrest, caused by excessive fluid intake.

Ms Lucas' mum, Mary Curran, said: "We felt that after a verdict like that, the hospital and the staff involved on the day would be held accountable."

Cygnet said it had since made improvements, including staff training and increased permanent staffing.

• If you are suffering distress or despair, details of help and support in the UK are available at BBC Action Line.

The BBC understands that Cygnet referred three nurses to the Nursing and Midwifery Council, but no action has been taken.

In May, the health and social care watchdog, the Care Quality Commission (CQC), concluded it could not launch a criminal investigation because of a "lack of evidence" linking "individual failures" back to Cygnet.

Ms Lucas' mental health worsened after a fall in Barcelona in 2017

The day before Ms Lucas died - 8 September 2022 - staff had seen her drink excessive amounts of water, smoothies and Coca-Cola quickly by midday - something a consultant later said she had never done before, the inquest was told.

She was monitored every 15 minutes for more than three hours but had only been seen through a window of a closed bedroom door, and was found unresponsive hours later.

Ms Curran, 60, said: "She [Lily] lay on the floor, on a hard floor, covered in her own vomit and faeces, and was left in that state until nearly 19:00 BST when they realised things were more serious than they thought."

The inquest was told she died in hospital the following day from cardiac arrest, caused by excessive fluid intake which was a consequence of her schizophrenia.

"She was in a place where we trusted that she'd be looked after. A place where she felt, we felt, she was safe and we could relax," Ms Curran added.

Ms Curran, who now lives in the Gower, Wales, described her daughter as "fantastic".

"She was a bundle of fun and the absolute life and soul of our family. She was just larger than life," she said.

She said she believed that she might still be alive if staff responsible for her had taken better care of her.

Ms Curran returned to Cygnet's Kewstoke Hospital for the first time since her daughter died to tell the BBC "no one has been held to account".

Ms Lucas, from Malmesbury, Wiltshire, had also been diagnosed with complex post-traumatic stress disorder.

Her mental health had worsened after a fall in Barcelona in 2017 - while celebrating her graduation as a mental health nurse from Bristol's University of the West of England.

She was referred to the ward in June 2022 as an NHS patient under the Mental Health Act for therapy and 24-hour care as a low secure unit, after years of care elsewhere.

Ms Curran said her daughter wanted to get better, and in her last social media post she had shared her dream of finishing treatment and travelling around Australia.

Understaffed to 'unsafe levels'

In the days before her death, Ms Lucas had been prescribed the antipsychotic drug, Clozapine, the inquest was told.

She complained to staff of nausea, hot flushes, and feeling unwell and her condition worsened from 7 September.

The inquest heard that on 8 September staff watched her vomiting and defecating on the ward, and offered her medication which she refused. Later, a nurse was heard "sternly" telling her to stay in her room.

The ward manager admitted the unit was understaffed to "unsafe levels" on the day she collapsed, the inquest was told.

The inquest jury concluded "gross failures" amounted to her neglect and there were "missed opportunities" to prevent her death. Clozapine was ruled out as a cause of death.

Ms Lucas (left) dreamed of completing her treatment to travel around Australia

An NHS review of the Milton Ward, launched in response to Ms Lucas' death, found "very large usage of agency staff" and "extremely high staff turnover".

Staff lacked experience in mental health, and some agency nurses did not know how to "use 999", it found.

The review said: "The story of Milton Ward shows what happens when culture becomes closed, in an environment already challenged by external staffing constraints and a pandemic."

It added bad news "was not welcomed, and was often ignored", and the service was "failing in plain sight" which was not realised "to this level of dysfunction until a serious event occurred in the ward".

The BBC understands the NHS pulled its patients from the ward in 2023 due to concerns raised in the review, which Cygnet then closed. Cygnet has confirmed there are now no low-secure wards at the hospital.

Ms Curran said a nurse had treated Lily "quite cruelly at times", revealing they once denied her tampons she needed, telling her to order them online.

That nurse was not working on the day she collapsed, but was disciplined internally by Cygnet, rather than in a public tribunal.

'Somebody needs to be held accountable'

Ms Curran's MP, Tonia Antoniazzi has spoken in Parliament to urge the government to prevent similar tragedies after hearing of Ms Lucas' "harrowing" death.

The Labour MP for the Gower said: "The thought that there are any more mums like Mary out there absolutely fills me with horror and I need to have the reassurances that actions are going to be taken," she said.

"We need to make sure that anybody's daughter, brother, sister, or friend that finds themselves in a vulnerable situation in a hospital… are safe and cared for properly.

"That is what has to come out of this for Lily's death and somebody needs to be held accountable for their actions."

Ms Antoniazzi also said she had raised concerns with Health Secretary Wes Streeting.

A Cygnet spokesperson said they "referred all relevant matters to the appropriate and regulatory and professional bodies, and complaints were investigated and dealt with through the proper procedures".

"Following the inquest, we responded to findings and implemented improvements, including staff training, physical health monitoring, and staff engagement during observations.

"We also increased permanent staffing and reduced agency staff to ensure continuity and familiarity with patients' needs," they said.

In September 2022, agency staff made up about 50% of staff on shift, and at the time of the inquest in April 2024 it was approximately 20%.

Cygnet Hospital Kewstoke is rated as "good" overall by the CQC.

The watchdog has the power to conduct criminal prosecutions if failures in care can be proved but said evidence around Ms Lucas' death "didn't meet the legal threshold required to proceed".

It added it may review the case if new evidence emerged.

On the day before she collapsed, Ms Lucas told her mum she had felt sick for days.

Ms Curran told the BBC she suggested her daughter brushed her teeth again which might "help alleviate the nausea".

"To which she said, 'I haven't got a toothbrush or toothpaste'. We were utterly shocked by that," Ms Curran said. It was their last conversation.

Following the inquest, Ms Curran said she left a career in social care to challenge Cygnet and also because the "trauma of losing Lily had taken its toll".

She said she had "lost faith in the system" but remained determined to fight for her daughter.