Lawyers Join Relatives In Calling For Improved Mental Healthcare For Young People

The family of a young woman found fatally injured in an “unsafe” mental health hospital are campaigning to improve care for others. 

Bonnie Newton, aged 20, was found in her room at Cygnet Hospital Ealing in West London. She had been an NHS patient at the hospital, which was 100 miles from her home in Wimborne, Dorset, for eight months. 

Risk assessments and care plans not updated by hospital

Despite a previous serious ligature incident, of a very similar nature, four months before her death, none of Bonnie’s care plans or risk assessments were updated to reflect this risk. No new risk assessment of environmental ligature points was conducted, while a previous audit was two months out of date, the inquest was told. 

Upon discovering Bonnie unresponsive, staff, who had tried to press personal and wall-mounted emergency alarms which did not work, carried out “ineffective CPR”, with Bonnie lying on her front. They did not use emergency equipment available until paramedics arrived 15 minutes later, West London Coroner’s Court heard.

Bonnie, who had a history of mental health issues, had suffered irreversible brain damage. She tragically died in hospital the following afternoon. 

The jury found there was insufficient evidence that she intended to take her own life.

Cygnet fined £1.53m in connection with Bonnie's death

Healthcare provider Cygnet was fined an unprecedented £1.53 million in connection with Bonnie’s death in a criminal prosecution brought by the Care Quality Commission (CQC). The regulator said that Cygnet had failed to mitigate known risks and ensure Bonnie’s safety.

Bonnie’s parents, Marie and Jon Newton, and Bonnie’s brother Alex have now spoken for the first time about their devastating loss. They have joined their legal team at Irwin Mitchell, which supported them at the hearing, in calling for improved mental health care among young people. 

Inquest finds safety issues in relation to Bonnie's care 

It comes after an inquest jury concluded that Bonnie’s death was contributed to by neglect. 

It added that “the lack of documentation at Cygnet was insufficient to provide Bonnie with a safe level of care” and that a lack of staff in management roles contributed to instability and caused a lack of oversight over New Dawn Ward, where Bonnies was a patient. 

Camilla Burton is an expert human rights lawyer at Irwin Mitchell representing Bonnie’s family.

Expert Opinion

“Bonnie was a young woman with her whole life ahead of her. Marie and Jon believe their daughter’s death was entirely preventable with the inquest hearing extremely worrying evidence about the unsafe care she received.

“Sadly, this isn’t an isolated incident. We continue to see too many cases of young people with mental health problems not receiving the level of care they deserve, often miles from home.

“Young people with mental health problems are some of society’s most vulnerable. We join Marie and Jon in calling for lessons to be learned from Bonnie’s death so other families don’t suffer a similar tragedy.” Camilla Burton

Mental health: Bonnie's story

Bonnie had been diagnosed with personality disorder and spent 18 months as an inpatient at a hospital near her home. 

She was transferred to the New Dawn ward of Cygnet Hospital Ealing on 20 November, 2018, under the Mental Health Act, so she could start dialectical behavioural therapy.

On 21 July, 2019, Bonnie became isolated and pre-occupied, the inquest heard. The following day, during a night-shift staff handover, a mental health nurse asked the team to ‘keep an eye’ on Bonnie. The court heard. 

Later that evening Bonnie asked staff for medication for her anxiety but remained on 15-minute observations. Following a video call with Bonnie, Marie called the ward concerned about her daughter. 

Bonnie was found by the only mental health nurse on duty just after 3.30am on 22 July. She died at 1.36pm on 23 July, 2019. 

Court hears of "unsafe" staffing levels

The inquest was told that one mental health nurse and two healthcare assistants were on duty on the night Bonnie was injured. 

At the time Bonnie was found, one healthcare assistant was on a break and the other was carrying out one-to-one observations on another patient. No attempt was made to bring additional staff from another ward to cover the break. The inquest was told that staffing levels on the night were “unsafe” and that a minimum of two nurses and two assistants were required to cover a ward.

Family reveals heartbreak and campaign for improved mental health care

Speaking on behalf of her family after the inquest, Marie, said: “There are no words to describe the effect that Bonnie’s death has had on our family. Our hearts are broken. The pain both mentally and physically is like nothing else. 

“Not only was Bonnie my daughter, she was my best friend. She was my world.

“Although Bonnie had her struggles, alongside her talent for singing and great sense of humour, she continued to be the most kind, polite, caring and wonderful daughter anyone could ever wish for. She will never be forgotten. What Bonnie had to go through shouldn’t happen to anyone. She didn’t want to feel the way she did, Bonnie was desperate to have a life without sadness.

“Bonnie was reluctant to transfer to Cygnet Ealing but was told she needed to so she could receive the dialectical behavioural therapy she had waited almost half her life for, and ultimately, for her to get better.

“However, she found it challenging and we found communication with the hospital was poor. Any responses we got seemed curt. All we were told was to “stop worrying and Bonnie was getting better.

“I’ll always believe that if Cygnet, who were entrusted to care for Bonnie, had looked after her properly she would still be with us now.

“We just hope by sharing our story we can improve care for vulnerable young people. I wouldn’t wish the pain we face each day on anyone.”

Support available

Find out more about Irwin Mitchell's expertise in supporting families with concerns about the care of a loved one detained in hospital at our dedicated protecting your rights section. Alternatively, to speak to an expert contact us or call 0370 1500 100.

More information is also available from several charities, including The Samaritans.