Failures in care led to Sussex woman's death, jury says

Jessie Eastland-Seares was found by staff during an hourly observation

A woman who took her life in a mental health facility faced "systematic failures in health and social care", a jury has concluded.

Jessie Eastland-Seares, who was 19, died at Mill View Hospital in Hove in May 2022.

Those failures caused Ms Eastland-Seares dysregulations that led to "regular bouts of self-harm" and ultimately her death, the jury said.

East Sussex County Council said it accepted the view of the jury.

The coroner recorded a narrative conclusion and will be making a prevention of future death report.

The jury said Ms Eastland-Seares' self-harm led to death by misadventure.

'Lessons to be learnt'

An East Sussex County Council spokesperson said: "We would like to extend our condolences to Jessica's family and friends."

They said the council would "continue to work with partners to identify lessons to be learnt and implement changes that will improve the way we support young adults with complex needs".

Ms Eastland-Seares was autistic, had a history of complex physical and mental health issues and self-harm, and had been diagnosed with dyspraxia, Ehlers-Danlos Syndrome, Attention Deficit Hyperactivity Disorder, sensory processing disorder, depression and anxiety, and disordered eating.

The coroner said there was a "totally inadequate level of community treatment" for people with autism.

On Friday, Ms Eastland-Seares' mother, Katherine Eastland, told the inquest that while her daughter was in assisted living and under Sussex adult mental health and social care services, her personal care needs were not met.

She said her daughter had urine-soaked sheets and used incontinence pads left next to her food.

At one point carers did not assist with her personal care needs because they said they had "run out of gloves", Ms Eastland said.

Katherine Eastland told an inquest her daughter felt staff did not care about her

Ms Eastland-Seares was found with a ligature around her neck by staff at the hospital.

Despite attempts to revive her, she was pronounced dead at the scene.

Earlier in the inquest, Ms Eastland said she believed her daughter's death was preventable.

She had been detained under the Mental Health Act since 4 March 2022 and admitted to Caburn Ward, a unit for people with acute mental health problems run by the Sussex Partnership NHS Foundation Trust.

On 3 February 2022, an assessment found her behaviour was "risky and unpredictable", making it difficult to support her in the community.

If you have been affected by any of the issues raised in this story you can visit the the BBC Action Line here.

Ms Eastland said "little interest" was shown in her daughter's physical difficulties when she was very young and she and her husband were not informed when she told a school counsellor in Year 5 she was hearing voices and having hallucinations.

The teenager's parents have said they felt services were "reluctant" to help them

Under the care of East Sussex County Council and children and adolescent mental health services, Ms Eastland-Seares had been an inpatient in hospital and care settings in the community since January 2017.

She was transferred to adult mental health and social care services when she turned 18 in December 2020.

Ms Eastland said: "Too often, services are divided so they cannot treat the whole person."

She said she felt lessons from reviews were not being implemented.

"From my experience, the voice of carers and cared for are not being heard, and that time is spent on managing us so that we bother them less," Ms Eastland said.