Parents Of Woman Who Died At The Caludon Centre Call For Improvements In Mental Health Services

Irwin Mitchell Secure Settlement From NHS Trust


The heartbroken parents of a young woman who died at a Coventry mental health facility have called for the NHS to make drastic improvements to mental health services after a CQC investigation highlighted several failings in their daughter’s care.

Donna Kirkland from Tamworth was just 30-years-old when she died from a combination of alcohol and drug ingestion on 22 August 2013, less than a month after being admitted to the Caludon Centre with a history of self-harming and depression.

Her devastated parents Susan and Robert Kirkland instructed specialist medical negligence lawyers at Irwin Mitchell to investigate her care at the Caludon Centre and now the law firm has secured an undisclosed settlement from the Coventry and Warwickshire Partnership NHS Trust for the family.

An inquest into Donna’s death held in July last year at Coventry Coroner’s Court 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 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. A report from the Care Quality Commission published last year identified more issues that the Trust must improve.

Expert Opinion
“Our investigations found that there were significant failures in Donna’s care. 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.

“We are disappointed that the Trust denied liability for the failures with Donna’s care, but agreed to settle the case out of court. We are pleased for the family that we have now been able to conclude their case and allow them to raise their concerns and awareness about mental health services in the West Midlands.

“This is unfortunately not an isolated case and at Irwin Mitchell we see similar shortcomings by other Trusts specialising in mental health. It is vital that they work together to share best practice, but also highlight errors that could have been prevented. This will ensure similar failings are not repeated and
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.

Irwin Mitchell has previously called on the 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.

Susan Kirkland, 66, said: “Our family has found it extremely difficult to come to terms with 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.

“Donna used to work as a carer at Linden Lodge care home before she became ill and she absolutely loved her job – she was brilliant with people and everyone used to warm to her instantly. She was wonderful to be around and she 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. The Coventry and Warwickshire Partnership NHS Trust has not taken responsibility for what happened to Donna which is a bitter blow for Robert and I, especially after the CQC investigation into patient care at the Caludon Centre.

“Above anything, we hope that speaking out about Donna will highlight to the NHS that mental health services in this country need to improve so that families like us do not needlessly lose their loved ones when they were meant to be at a trusted facility.”

Sometimes mental health professionals can fail in the duty of care. If you or a loved one has suffered due to professional or medical negligence we can help you to claim compensation. Visit our Mental Health Negligence Claims page for more information.