Essex coroner warns of more deaths due to lack of mental health care

Morgan-Rose Hart died a week after being found unresponsive at the Derwent Centre in Harlow

A coroner overseeing a teenager's inquest has warned there will be more deaths unless mental health services improve for autistic people at risk of self-harm.

Morgan-Rose Hart, 18, who had ADHD, autism and a history of mental illness had been a patient at a unit in Harlow, Essex, for three weeks.

An inquest jury concluded she died by misadventure contributed to by neglect.

Essex County Council said it would respond to coroner Sonia Hayes' report.

Ms Hart, from Chelmsford, died in hospital six days after she was found unresponsive in the bathroom of her mental health accommodation in the Derwent Centre in Harlow, Essex in July 2022.

The inquest into her death heard staff observations were falsified and critical observations were missed.

In her Prevention of Future Deaths report, Ms Hayes said: "There is a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks in Essex both inpatient and in the community."

She added: "During the course of the inquest the evidence revealed matters giving rise to concern.

"In my opinion, there is a risk that future deaths will occur unless action is taken."

The report has been sent to Essex County Council and Essex Partnership University NHS Foundation Trust (EPUT).

A spokesperson for EPUT, which runs the unit in which Ms Hart was a patient, said: "Our condolences remain with Morgan-Rose's loved ones following their tragic loss.

"We remain absolutely committed to ensuring improvements are embedded throughout the organisation, so that all patients receive the high quality and compassionate care they deserve.

"We are thoroughly reviewing the coroner's findings and will respond to the report in full in due course."

An Essex County Council spokesperson said: "We wish to offer our deepest sympathies to Morgan-Rose's family and friends on their sad and tragic loss.

"We are aware of the Prevention of Future Deaths report relating to Morgan-Rose and will be responding, as directed by the coroner, in due course."

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