Specialist Lawyers Instructed To Support Loved Ones Through The Inquest Process

An inquest jury at Essex Coroner’s Court has concluded that the absence of specific risk assessment concerning access to knives, and inadequate processes and poor controls around access to knives, may have contributed significantly to the death of Marion Michel, who was detained under the Mental Health Act at Brockfield House, a secure mental health inpatient unit in Wickford managed by Essex Partnership University NHS Foundation Trust (EPUT).

Marion died of self-inflicted injuries after being found unresponsive by staff on 4 March 2022. She was 56 years old. On the day of her death, Marion had been allowed unsupervised access to a large carving knife to prepare a meal for herself. The jury did not record a conclusion of ‘suicide’ as Marion’s intention at the time was not clear.

Marion was born and raised in Jersey, and her family describe her as “kind and generous with a lovely smile and a hearty and at-times mischievous laugh”. Marion had travelled widely, but Jersey was always important to her.

Marion was diagnosed with paranoid schizophrenia in 1998, however this had been in remission for some years. She had a history of intense periods of mental illness, often with rapid and unexpected deterioration, when she would hurt herself and, on two occasions, her partner.

Marion was moved to Brockfield House in 2018, after having been convicted of assault with a knife that year. It was there that she was assessed as having traits of Emotionally Unstable Personality Disorder.

Marion was transferred from Fuji Ward to Aurora Ward – a medium secure unit – in September 2021. Aurora Ward is a ward for patients who are nearing discharge to the community. At the time of Marion’s death preparations were being made for her transfer into supported accommodation later in the year.

Marion enjoyed making use of her unescorted perimeter and area leave. However, at the time of her death she had been subject to a 17-day Covid-19 lockdown on the ward, meaning she was unable to see family or follow her usual routine.

It was known that loneliness was a key trigger for Marion and just two days before her death her flatmate, to whom she was very close, had moved out of their shared flat and into a separate flat on the ward.

Marion’s consultant psychiatrist gave evidence at the inquest that Marion was most at risk of a violent episode when she was calm and quiet. However, in the risk profile carried out on 2 March 2022, the mental health nurse stated she was looking for ‘aggressiveness’ and ‘mood swings’.

Marion had been preparing for a meeting in relation to her housing. On the morning of her death, staff wrongly informed her that the meeting had been brought forward to that day. These changes coincided with a break in her DBT therapy and her psychological work coming to an end.

As part of the increased freedoms on Aurora Ward, Marion was able to self-cater and prepare meals.  Throughout her time at Brockfield House Marion have never undergone a formal risk assessment to determine whether it was safe for her to have access to knives, given her risk profile and history. 

A functional risk assessment had been carried out on one occasion in June 2019 to assess whether she was able to use knives competently when cooking.  Her access to sharp items had not been reviewed since her admission to Aurora ward. Staff nonetheless issued knives to Marion up to three times a week, although this was rarely recorded in the logbook.

On the day of her death, Marion requested a knife to prepare her lunch at 11:15am. Staff issued one but did not carry out any follow up when it was not returned. Staff found Marion in her bathroom at 12:00pm, having inflicted fatal injuries.

The jury conclusions

The jury concluded that apart from the ‘functional’ assessment of Marion’s ability to use sharp knives for cooking and meal preparation in June 2019, there had been no specific risk assessment in relation to her access to knives, despite a history of previous incidents of self-harm and violence involving the use of knives. The jury concluded that the absence of such a risk assessment possibly contributed significantly to Marion’s death.

The jury also concluded that insufficient consideration was given by clinicians and staff to the known potential triggers for Marion to suffer a sudden and extreme deterioration in her mental state which could lead to violence or self-harm. This was also found to have possibly contributed significantly to Marion’s death.

Finally, the jury found that there was a missed opportunity for staff to consider the cumulative effect on Marion’s mental state of several recent changes to her routine and living arrangements, including the impact of a Covid-19 lockdown and the patient with whom she had been sharing two-bedroom flat on the unit having moved out two days prior to her death. The jury concluded that this missed opportunity possibly contributed significantly to Marion’s death.

The government announced recently that an inquiry into mental health related deaths in Essex between 2000 and 2020 will be put on a statutory footing under the Inquiries Act 2005. As Marion’s death took place in 2022, it does not come within the scope of the inquiry.

Before the inquest, EPUT informed the Coroner that, following its internal investigation into Marion’s death, it is implementing an ‘action plan’ to improve services which includes a “robust process” for issuing knives, including a new protocol and risk assessment tool as well as a regular audit of use. Secure mental health services will also review how news and updates to patients are delivered.

Following the jury’s conclusion, Marion’s family said: “Marion was a much-loved daughter, sister, aunt and friend, and she is very much missed. She was kind, generous and loyal to those she loved, and she maintained strong links with friends and family, including after she moved away from Jersey.

“We had assumed Marion would be safe in a secure setting and risk assessments and robust policies were in place to ensure this. It has been a real shock to discover this has not been the case for Marion and we hope that EPUT is taking the necessary steps to improve the situation for the future and explain to relatives what safeguarding measures are in place to keep their loved ones safe. We hope that this has served as a wake-up call for EPUT.”

“Marion had struggles with her mental health, but she had been looking forward and planning towards being discharged from Brockfield House later in 2022. We will never know exactly what Marion was thinking and what led her to do what she did. We appreciate the thorough investigation carried out into her death by the Coroner and the jury, and we hope that changes made following Marion’s death will reduce risks to other patients in future.”

Expert Opinion

“Sadly I never met Marion, but it is clear from her family that she was a unique, intelligent and complex person, who was loved and appreciated by many people. Marion was detained for treatment under the Mental Health Act, and was rebuilding her life and working towards a planned discharge and reintegration into life outside hospital at the time of her death.”

“It is vital that we as a society ensure that people who are detained for mental health treatment are given the care and support they need, and that robust processes are in place to assess and manage any risks to themselves or other people. In Marion’s case, the jury heard detailed evidence and concluded that there was no assessment of the risk that might be posed when she had access to knives, and tragically this may have contributed to her death.”

“As the legal team for Marion’s family, we join them in hoping that changes made following her death will lead to a safer environment for patients and staff in mental health units, both in Essex and across the country.” Oliver Carter - Associate Solicitor

Jodie Anderson, Senior Caseworker from the charity INQUEST, said: “The professional inertia in Marion's care from those who saw her as a model patient, was destructive and dangerous. This generic one size fits all approach was one that led staff to miss or misunderstand the increased risk caused by various cumulative changes that were taking place in her life. The investigation by EPUT that followed Maron's death failed to highlight these key issues or identify meaningful learning, highlighting once again the urgent need for independent investigations into all deaths in mental health settings."

Marion’s family are represented by Oliver Carter and Ellie Mallett, from the public law and human rights team at Irwin Mitchell, and Caroline Allen, a barrister at 39 Essex Chambers. The charity INQUEST is also providing support to Marion’s family.

The inquest into Marion’s death was heard by HM Area Coroner Sean Horstead, sitting with a jury, from 5-14 July 2023, at Essex Coroner’s Court, Seax House, Victoria Road South, Chelmsford, Essex, CM1 1LX.