Coroner demands improvements after woman died at a Priory hospital

A coroner today demanded action from an under-fire health trust after a young autistic woman was found unconscious at a psychiatric hospital more than 250 miles from her home and later died.

Lauren Bridges, 20, of Bournemouth, Dorset, was an inpatient at the Priory Hospital Cheadle Royal in Greater Manchester at the time nearly two years ago.

In September, a jury inquest heard Miss Bridges had been found unconscious in her en suite bathroom at Cheadle Royal on February 24 last year at about 10pm.

The former straight-A schoolgirl was taken to the nearby Wythenshawe Hospital and her family travelled six hours from the south coast to be with her.

A clinical decision was then made after consultation with relatives including her mother Lindsey to end her life support and Miss Bridges died there two days later.

The inquest at South Manchester Coroner's Court in Stockport heard four weeks of evidence before concluding that Miss Bridges did not intend to take her own life.

READ MORE Mental health hospital where three young women died in less than two months is ordered to improve or face 'enforcement' action after inspectors find string of safety failures

Jurors also found there were 'missed opportunities' to find her a bed closer to her home during what was a seven-month admission.

Miss Bridges had been diagnosed with Autism Spectrum Disorder and Emotionally Unstable Personality Disorder, and spent four years detained at six different institutions.

Now, coroner Andrew Bridgman has written to Dorset Healthcare University NHS Foundation Trust raising his concerns in a Prevention of Future Deaths report.

He stated that the trust's 'standard of record keeping was inadequate' and said he was concerned that an 'out-of-area hospital overview' document was not updated 'timeously and correctly'.

Mr Bridgman added that 'it can be inferred from the absence of any documentation regarding discussions about Lauren's repatriation to an available bed that no such discussion took place'.

The report states: 'During the course of the inquest it was apparent that Dorset Healthcare NHS Trust's standard of record keeping was inadequate.

'Among other things, Lauren's name did not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed as being in an acute bed not a PICU (psychiatric intensive care unit).

'There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the five months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim.'

The coroner's report went on to note that during the inquest, the health trust 'admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed'.

In response to this, the coroner added in his report: 'Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of this omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest. 

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

Speaking in September, Miss Bridges's mother Lindsey said her 'beautiful, kind' daughter was 'horribly failed' by the mental health system.

She added: 'Sending mental health patients hundreds of miles from home to receive treatment does not work. Lauren didn't want to die. She was desperate to escape a hospital that was making her mental health worse. Our concerns and Lauren's requests to come home were ignored.'

A spokesperson for Dorset Healthcare University NHS Foundation Trust told MailOnline today: 'Our deepest sympathies go to Lauren's family and friends for their terrible loss. We can't imagine their pain and grief.

'We listened very carefully to all the evidence presented at this inquest and fully accept that the systems we had in place to bring people back to Dorset and closer to home were not what they should have been at the time of Lauren's death. 

'We profoundly regret that we could not respond to Lauren's need to be nearer to her home and her family. Our priority is to address the issues related to Lauren's tragic and untimely death.'

And a Priory spokesperson said: 'The unexpected death of a young adult is devastating and we would like to express our sincere condolences to Lauren's family. We fully support all initiatives for patients to be treated closer to home and our criteria for admitting patients is based on the nearest available bed.

'Our hospital teams work hard to ensure patients can be discharged safely and at the earliest opportunity. Since Lauren's sad death, we have put in place a stronger and more proactive process for patients whose discharge from hospital is delayed, to improve communications and escalate issues more quickly with the commissioners and NHS home services responsible for securing the patient's next placement.

'We continue to invest in making our wards safer. We will now reflect on the jury's findings and work openly with the NHS, commissioners and regulators to ensure any further learnings are put into practice. We remain committed to providing safe and effective care to our patients.'

It comes after the Daily Mail reported in May that three young women including Miss Bridges who were patients at Cheadle Royal had died in less than two months, leading to it being ordered to improve or face 'enforcement' action following a string of safety failures identified by inspectors.

Cheadle Royal was told it 'requires improvement' overall and its child and adolescent wards were 'inadequate' following an unannounced inspection from the Care Quality Commission watchdog.

Concerns were raised after the deaths of Miss Bridges along with Desiree Fitzpatrick, 30 and Beth Matthews, 26, which led to the inspection in January earlier this year.

And that came after Inquest, a charity supporting bereaved families, identified 20 deaths within the last decade linked to concerns about patient care.

One of the cases included 23-year-old personal trainer Matthew Caseby, who stepped in front of a train after escaping from a Priory-run hospital in Birmingham. His inquest concluded with a finding of neglect in April last year.

In 11 of the 20 cases, a coroner had written a Prevention of Future Deaths report urging changes to care arrangements.

Cases highlighted by Inquest also included two deaths of Cheadle Royal Hospital patients in 2014.

The CQC inspection focused on three wards for children and young adults at the hospital.

Inspectors recommended 15 separate improvements after finding shortcomings in 'safe care and treatment', 'premises and equipment', 'systems' and 'staffing'.

Their report said high levels of restraint were used and there was a lack of monitoring after tranquilisation or for side-effects from medication.

In January, an inquest found mental health blogger Miss Matthews, from Cornwall, died of suicide contributed to by neglect when she ingested a poisonous substance ordered online on March 21, 2022.

Although she was not supposed to open her own post, the inquest found 'inconsistencies' in how staff implemented the policy and management admitted a care plan was not followed.

Meanwhile, Ms Fitzpatrick died after being found unresponsive in her room last January 23. She had been admitted days earlier due to risks of self-harm and for alcohol detoxification.

Although taking a number of medications from her GP, the 30-year-old was then prescribed additional drugs at the hospital.

After an inquest last November, Mr Bridgeman found she choked in her sleep after receiving 'inappropriate' medication which had caused 'significant sedation'.

For confidential support call the Samaritans on 116123, or visit a local Samaritans branch. See samaritans.org