Case held before HM Coroner Professor Paul Marks, Coroners Court Hull & East Riding
Repeated failures at Westlands Mental Health Unit were identified at the conclusion of an inquest of a detained patient in Hull
On 12 May 2015, Helen Millard was found unconscious at the Westlands Mental Health Unit (under the care of Humber NHS Foundation Trust) having used an item of clothing and the taps on the sink in a shared bathroom to take her life using a ligature. Helen was pronounced dead at Hull Royal Infirmary in the early hours of 13 May 2015.
Helen had a history of mental ill health having been diagnosed with Emotionally Unstable Personality Disorder (Borderline Type). She was known to staff at the Westlands Unit having been an in-patient (voluntary and compulsory) on several occasions since 2012. Since her admission to the Westlands Unit on 2 March 2015, Helen’s records show over 100 attempts at self-harm / suicide using a ligature, some using these same taps on previous occasions in attempts to take her life.
The jury concluded:
“We find that the trust knew that the taps were a known risk and a known ligature point for Helen and feel that once the risk had been flagged in the report of 2012, works should have been expedited”
Helen’s husband Jon said:
“The world will truly be a little dimmer without Helen in it; she was such a light and will be deeply missed. I fully believe this to be true, and I hope that the changes introduced following her death will protect others who experience similar issues”.
Deborah Coles, Director of INQUEST said:
“The key question all families ask is why swift action is not being taken to remove known ligature points identified following CQC inspections? Why is there no proper system of national learning and accountability to prevent future deaths? It beggars belief that after so many deaths and inquest findings exposing similar failures, our mental health wards continue to be unsafe.”
Kulvinder Gill from Howells Solicitors, acting on behalf of Jon Millard said:
”What all the medical experts in this case agreed on is that the Westlands Unit was not safe. It is unacceptable that vulnerable patients detained for their own safety should be able to repeatedly place themselves in danger in the way that Helen did. Although Humber NHS Trust undertook annual ligature audits, they were slow to action and undertake essential works. Using the national tool kit for ligature audits, the taps used by Helen would only ever be classed as an amber risk point because they are were less than one meter in height. Research studies show that it is not necessary to be suspended to die using a ligature. The toolkit requires updating to reflect the risks posed by all ligature points and NHS Trusts need to put in place clear guidelines so that budgets are properly allocated to ensure essential works are undertaken so that units such as Westlands are safe.
INQUEST has been working with the family of Jon Millard since October 2015. The family is represented by INQUEST Lawyers Group members Kulvinder Gill of Howells Solicitors and Richard Baker of 7 Bedford Row.