Irwin Mitchell Instructed By Two Families Whose Loved Ones Died At Caludon Centre In Coventry

Specialist Medical Negligence Lawyers Are Concerned About Patient Safety At Mental Health Facility


Medical negligence lawyers at Irwin Mitchell say they have concerns about patient safety at a Coventry mental health unit after being instructed by two families to investigate the circumstances surrounding their loved one’s deaths whilst inpatients at the facility.

The leading law firm says there are ‘shocking’ similarities in shortcomings by staff at the Caludon Centre in Coventry in two cases it is investigating involving women taking their own lives when they should have been under close supervision.

Irwin Mitchell is now calling on Coventry and Warwickshire Partnership NHS Trust to confirm it is improving its services at the centre after the Care Quality Commission (CQC) recently published a report*, which highlighted the following general failings:

• The centre did not always adhere to the Mental Health Act’s Codes of Practice;
• On some wards, staff were not trained specifically to meet patient’s needs;
• There were regular shortages of staff on the wards;
• Staff were not learning from incidents that had taken place to prevent them from happening again.

The law firm has secured an admission of liability from the Trust in relation to the death of a 41-year-old woman when the nursing staff failed to observe her whilst in a communal bathroom allowing her to hang herself in 2012.

Her husband said: “My wife stayed at the Caludon Centre on a number of occasions and each time I was assured that this was going to be a place of safety for her, but it ultimately led to her death after they failed to give her the care she needed and deserved.

“I am pleased that the Trust has admitted liability for the failings in her case and I hope that after the recent investigation by the CQC that the standard of care at the centre will be improved to prevent any future tragedies.”

Now, medical negligence lawyers at Irwin Mitchell have been instructed by devastated parents Susan and Robert Kirkland whose daughter, Donna, died of a combination of alcohol and drug ingestion on 22 August last year aged 30, less than a month after being admitted to the Caludon Centre with a history of self-harming and depression.

During an inquest into Donna’s death in July 2014 at Coventry Crown Court evidence was heard that staff at the Caludon Centre had failed to follow the observations policy at the time of her death. The Jury concluded that had the observation and engagement policy been adhered to; there may have been the potential to identify a deterioration in her condition. It was found that Donna had consumed that alcohol hand gel which was available to the patients within the unit. 

The Coroner was concerned that patients had unlimited access to alcohol based hand sanitising gels and has since made a recommendation to the Trust that action should be taken to prevent future deaths.

Expert Opinion
We have now been instructed by two families who believe their loved ones experienced substandard care at this mental health facility and the similarities in each case are shocking. We are very concerned about the failings highlighted in the recent CQC report.

“It was clear that Donna’s depression was severe, she was open with staff and her family about the feelings she had been experiencing because she acknowledged something was wrong and wanted to get better. Donna’s family trusted staff at the Caludon Centre to care for her and are frustrated and angry that guidelines do not appear to have been followed to protect their daughter’s safety.

“We are also deeply concerned to learn of the failings identified in the CQC report as it suggests patient safety may have been compromised for some time, putting other patients at risk of not receiving the appropriate care needed to keep them safe.

“It is vital that the Trust learns lessons from the failings identified in each of these cases and the CQC review and improves standards of care so that other families do not lose their loved ones in such tragic circumstances again in the future.”
Tom Fletcher, Associate
When Donna was admitted to the Caludon Centre she was placed on level 2 observation, meaning she should be closely monitored every 15 minutes. Following a review by a psychiatrist, it was recommended that Donna should be placed on level 3 (within constant eyesight) observation as she had made several attempts to escape from the ward and had stated that she would like to get off the ward and end her life. In spite of this, the observation levels were not increased.

During the evening of 21st August 2013, multiple members of staff were tasked with monitoring Donna in her bedroom, but failed to carry out the correct observation and did not enter her bedroom at all throughout the night to check her condition. She was found at 7:25am the next morning unresponsive and staff were unable to resuscitate her.

Donna’s mum, Susan Kirkland, age 66 from Tamworth, said: “Our family has been left completely heartbroken after losing our daughter, especially as we had put our trust and faith with the staff at Caludon Centre to make sure she was getting the best possible care.

“Before she was ill, Donna used to work as a carer at Linden Lodge care home and she absolutely loved her job. Donna had so much to give, she was so loving and caring to those around her and brought so much joy and happiness to mine and Robert’s lives.

“We are very disappointed that the care Donna received was below the recommended standard and that there were many opportunities through the night where she may have been saved. To find out that another family is also grieving for the loss of their loved one due to the substandard care at the Caludon Centre is unimaginable. We hope that now that the CQC has completed their investigation and found several aspects of patient care that falls below the recommended standard that improvements will be made.”