Essex mental health unit neglect led to teen's death - inquest

Morgan-Rose Hart died a week after the incident at the Derwent Centre in Harlow

A failure of basic protocol at an NHS mental health unit led to a patient dying by misadventure contributed to by neglect, an inquest jury has concluded.

Morgan-Rose Hart, 18, died after she was found unresponsive at the Derwent Centre in Harlow, Essex, in July 2022.

The inquest heard staff observations were falsified and critical observations were missed.

The Essex Partnership University NHS Foundation Trust (EPUT), which runs the unit, said lessons had been learned.

Area coroner Sonia Hayes, sitting at the Essex coroner's court, said she would make a Prevention of Future Deaths report.

Falsified notes

Ms Hart, from Chelmsford, had ADHD, autism, a history of mental ill health and self-harm, and had been a patient at the unit for three weeks.

On 6 July last year she told staff she was going to take a shower.

Staff carried digital tablets, which would sound an alarm when a patient had been in their bathroom for longer than three minutes, the jury was told.

Ms Hart's alarm sounded but was turned off after 21 seconds, with no-one checking in on her, the coroner was told.

She was not checked for almost an hour by which time she was unresponsive.

Ms Hart died at Princess Alexandra Hospital in Harlow a week later.

Staff employed by EPUT routinely did not carry out face-to-face checks on Ms Hart, the inquest heard, with three workers admitting to falsifying observation notes from the day of the incident.

Ms Hart's mother described her as "caring and funny"

Speaking after the inquest, her mother Michelle Hart said: "This world has lost one of the best, and life will never ever be the same without her.

"We hope all those involved in her care finally learn from their mistakes so that no other family has to go through what we've been through."She described her daughter as "caring and funny, with a huge passion for animals and wildlife".

In a statement, Paul Scott, the chief executive at EPUT, said: "Morgan-Rose was admitted to our care when she needed us most, but mistakes were made which should never be repeated and for that I am sorry.

"Lessons have been learned and I am absolutely committed to ensuring improvements are embedded throughout the organisation so that all patients receive the high quality and compassionate care they deserve."

EPUT added that a clinical psychologist now supported young patients transitioning to adult mental health wards, along with "nurse transition champions" across the trust.

Staff training on patient monitoring had been "enhanced", with the alarm system modified to repeatedly alert staff about patients using the bathroom for a period of time "that could present a risk to their safety".

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