Death Found To Have Been Contributed To By Royal Sussex County Hospital “Neglect”

A mum is calling for lessons to be learned after an inquest into her daughter’s death in a private psychiatric hospital concluded.

Suzanne Roberts, 33, died on 18 October, 2015, while she was a patient at The Dene in Goddards Green, West Sussex.  She had complex mental and physical health needs.

Four days prior, Suzanne was discharged from the Royal Sussex County Hospital where she had been receiving treatment for an arm injury.  She also had a high output stoma and had been suffering with an acute kidney infection (AKI).

Sussex Police launched a criminal investigation into the running of The Dene following the death of Suzanne, originally from Knighton, and two other women. No criminal charges were ever brought.

Suzanne’s family instructed specialist lawyers at Irwin Mitchell to obtain answers as to why she died.

The family and their legal team at Irwin Mitchell are now calling for lessons to be learned. It comes after an inquest jury at Centenary House in Crawley concluded that “the decision by staff at the Royal Sussex County Hospital to discharge Suzanne on 14 October was not appropriate and probably caused her death.”

Suzanne’s cause of death was an injury and infection to the kidney. She was also suffering from “chronic dehydration”, an inquest heard.

The jury found that Suzanne’s death was “contributed to by neglect, due to the fact that blood test results showed high levels of potassium, [which] eventually led to heart failure”.

The coroner directed the jury to consider a conclusion of neglect following the findings of inadequate care Suzanne had received at the Royal Sussex University Hospital.

The inquest also found that The Dene “failed to meet (Suzanne’s) physical needs during her time there.”

Expert Opinion

“The last few years and attempting to come to terms with Suzanne’s death has been incredibly difficult for Loraine and the rest of Suzanne’s family. They have all had a number of concerns about the care Suzanne received.

Sadly during the course of the inquest worrying evidence was heard which they believe has validated those concerns.

While nothing can make up for their loss we are pleased that we have been able to secure the vital answers that Loraine deserved as to how and why her daughter died.

It is now vital that lessons are learned so no other family has to suffer in the same way.

We will continue to support Loraine and the rest of Suzanne’s family at this distressing time.”
Juliet Spender - Associate Solicitor

Following the inquest, Suzanne’s mum Loraine and dad Glyn said: “It has been such an awful couple of weeks, having to relive what happened to our daughter in her final days and how she died.

“Although Suzanne had some troubles in her life, she was very loved by her family and is still greatly missed.  She was very clever and had so many artistic talents.  Had she had the right support, I am sure she would have been a very successful person.

“Since she was a child, we have struggled to get the support she needed, which could have made the difference to her being here today.

“While nothing will ever bring her back, we are grateful that the inquest has ended and there are now answers as to why Suzanne is no longer with us.  All we can hope for now is that lessons are learned so no other family has to face what we have.”

Anita Sharma, Head of Casework at the charity INQUEST who worked with the family, said: “The findings of this inquest expose the shocking level of neglect, which resulted in Suzanne’s premature and avoidable death. Without the tenacity of the family this may never have come to light.

“They stand alongside the families of the other women who have died, and others who have suffered poor care at The Dene, a private hospital which has profited  from services commissioned by the NHS and where  inadequate care has been well documented. Yet so far no individual or corporate body has been held to account for the failures of Partnerships in Care, now part of the Priory Group.”

Background

Suzanne had been known to mental health services since childhood and was admitted to the The Dene on 24 August, 2015.  At the time, the hospital was run by Partnerships In Care Ltd, but was taken over by the Priory Group in 2016.

A consultant forensic psychiatrist working at The Dene when Suzanne was admitted  told the inquest jury that the hospital was “short staffed.”

During her time at The Dene, Suzanne was admitted to NHS hospitals on a number of occasions, including three times when she arrived at Royal Sussex County Hospital’s accident and emergency department.

The inquest jury was told that during these attendances, blood test results showed a worsening pattern of dehydration and kidney infection and injury.

An expert in renal and intensive care medicine said that the blood test results from Suzanne’s last admission on 12 October showed her renal function had been halved.  He added that had Suzanne received inpatient treatment rather than being discharged, then she would not have died.

However, Suzanne was discharged, with the discharge summaries from the Royal Sussex County Hospital showing no documentation of the acute kidney injury or high potassium levels.  In addition, they were sent to her GP in Derby rather than The Dene. 

The consultant orthopaedic surgeon who discharged Suzanne said “I feel I failed (Suzanne) very badly” and that discharging her with renal failure was a “catastrophic error.”

Suzanne died four days later.

Katherine Stamp, 30, died at The Dene on 26 March, 2015. Naomi Scott, 27, died on 1 February, 2016, in general hospital, after receiving care at The Dene. Their inquests took place in November 2019.

The Dene was the subject of a Channel 4 Dispatches documentary “Undercover: Inside The Priory” which aired in February 2018.

The current director of The Dene (now The Priory Hospital Burgess Hill) gave evidence at the inquest regarding changes that have been made there since Suzanne’s death.

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