Jury Concludes Failings At Mental Health Unit ‘Significantly Contributed’ To Death Of Liverpool Woman

Irwin Mitchell Represents Family At Inquest


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The devastated parents of a 23-year-old woman who died on the Harrington Ward at the Broadoak Unit in Liverpool have said more must be done to keep patients safe after an inquest was critical of a history of severe failings in her care.


Laura Mottram from Liverpool was found dead by staff at the mental health unit on 18 February 2015 and her parents have expressed concerns about her treatment at the facility.


Laura’s parents, Jenny Smith and Joe Mottram instructed medical negligence lawyers at Irwin Mitchell to investigate the care their daughter received from the Mersey Care NHS Foundation Trust.


At an inquest into Laura’s death at Liverpool Coroner’s Court the Trust apologised to Laura’s parents for the care she received and admitted that the Harrington Ward was “chaotic and dysfunctional” at the time of Laura’s death.


Coroner Andre Rebello told the jury that the NHS Trust had also admitted other errors, including a lack of continuity in Laura’s care and a failure to conduct a risk assessment. The jury heard that Laura needed psychological therapy that was not available on the ward.


Today, the jury recorded a narrative verdict into her death which was listed as compression of the neck due to the application of a ligature and that Laura’s intention was unclear.


The jury also concluded that from the evidence provided there was a history of severe failings to provide an adequate environment and care at the Broadoak Unit and that it is more likely than not that they significantly contributed to the event of Laura’s death.


Ayse Ince, a specialist medical negligence lawyer at Irwin Mitchell, representing Laura’s parents, said:


Expert Opinion
“This tragic case highlights real concerns about the quality of the care and treatment provided by the Mersey Care NHS Foundation Trust to some of the most vulnerable people in its care.

“The Trust conducted at internal investigation into standards at the unit shortly after Laura’s death as it followed the death of two other patients at the unit. Clearly, these issues need to be addressed by the Trust so other parents do not have to go through what Joe and Jenny have.

“They have understandably been left absolutely devastated by Laura’s avoidable death. As the jury’s conclusions have made clear, there were a significant number of basic failures in the care provided to Laura, which ultimately led to her tragic death.

“It is imperative that lessons continue to be learned from this, and similar, tragic cases at the Broadoak Unit so that vulnerable detained patients are provided with an appropriate level of care in order to prevent similar deaths occurring in the future.”
Ayse Ince, Solicitor


Laura’s father Joe Mottram said: “Laura was a wonderful daughter and spent a lot of her time volunteering to help animals and she loved telling us all about the enjoyment she got out of her volunteer work on a local farm.


“She loved and cared about her family and we will always remember her as the kind, happy, generous and funny person she was. We all adored her and feel absolutely devastated that she is no longer with us.


“We have struggled to come to terms with everything that happened to Laura at the Broadoak Unit and our suffering has been made worse knowing that knowing that there were failings in the care provided by the hospital.


“Laura was a vulnerable young woman in crisis and it is difficult for us to understand why she was not better protected. The Trust has admitted these mistakes and apologised to us, but we know nothing will bring Laura back.


“We can only hope that the Trust now makes the necessary changes to ensure that vulnerable people it is responsible for are safe in its care.”


A serious incident review into Laura’s death conducted by Mersey Care NHS Foundation Trust stated that in late 2014 and early 2015 the Harrington ward had “very high levels of adverse incidents, very high sickness absence, low staff morale and lots of incidents involving ligatures”.


Poor documentation and record keeping were also identified during the investigation. It was also found that no formal risk assessment had been undertaken, that there was a failure to diagnose Laura’s psychosis and that there was no real plan in place for Laura’s care.


Reading out the conclusion, Coroner Andre Rebello thanked Merseycare for their candour, frankness and for fixing a deficit in mental health services in the region. He also highlighted that no deaths had been reported to him since Laura’s.

If you or a loved one has suffered as a result of mental health negligence, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.