Essex mental health patient's access to knives 'possibly' led to death

Marion Michel, 56, died of self-inflicted stab wounds at the Essex unit in March 2022

A lack of risk assessment over a mental health inpatient's access to knives "possibly" contributed to her death, an inquest jury has concluded.

Marion Michel, 56, died of self-inflicted stab wounds while at Brockfield House in Wickford, Essex, on 4 March 2022.

Her family said they hoped the conclusion would be a "wake-up call".

The NHS trust that runs the unit said it took "immediate action to strengthen risk assessments" following her death.

"We had assumed Marion would be safe in a secure setting and risk assessments and robust policies were in place," the family statement said, following the inquest at Essex Coroner's Court in Chelmsford.

"It has been a real shock to discover this has not been the case for Marion and we hope that [the NHS trust] is taking the necessary steps to improve the situation."

Ms Michel was diagnosed with schizophrenia in 1998 and was transferred to Brockfield House from prison following a conviction for stabbing her partner in 2018.

She was in the unit's Aurora ward at the time of her death, where staff prepare patients for discharge.

The inquest heard she was trusted to use an 18cm (7in) kitchen knife to prepare food.

'Potential triggers'

Ms Michel was found locked in a bathroom with 30 self-inflicted wounds to her chest and neck.

The jury concluded she took her own life, but did not record a verdict of suicide because "we were unable to determine her intention at the time".

There was an "absence of a focused risk assessment" regarding her "unsupervised" access to knives, the jury said.

"This possibly contributed significantly to Marion's death," said the jurors.

They also said clinicians and staff gave "insufficient consideration" to "known potential triggers" that could have caused an "extreme deterioration in her mental state".

Marion Michel had been looking forward to being discharged from the unit in time for her father's birthday, the inquest heard

Ms Michel's family described her as much-loved, kind and loyal.

A spokesperson at the Essex Partnership University NHS Foundation Trust (EPUT), which provides mental health services, said: "We took immediate action to strengthen risk assessments for patients who prepare their own meals and review procedures to ensure emergencies on the ward are responded to as quickly as possible."

EPUT said it provided services to 100,000 patients at any one time and that £40m had been invested in improvements to services in "recent years".

An ongoing public inquiry is investigating the cases of 2,000 people who were under the care of NHS mental health services in Essex when they died between 2000 and 2020.

Find BBC News: East of England on Facebook and Instagram. If you have a story suggestion email [e-mail] or WhatsApp on 0800 169 1830