THE family of a woman who died after being found hanging in her room at a mental health hospital have expressed their disappointment in the failures that were found with her care.

Lauren Finch was discovered hanging in her room in the Westleigh Ward at Atherleigh Park in Leigh on September 17, 2018.

She died seven days later on September 24 at the Royal Bolton Hospital at the age of 23.

After an inquest at Bolton Coroner's Court from October 1 to 11, the jury found Lauren, from Wigan, died as a result of suicide and left a number of critical findings.

Lauren’s family said: "Firstly, we are thankful to the Coroner and jurors for finally giving us the answers we have sought for over the last 12 months.

"We are able to say with great disappointment that the services that we entrusted to look after our precious Lauren and which also look after so many other vulnerable people in the borough have admitted to and have been found to have significant failures in their line of care.

"We hope that this inquest will prevent further deaths in the future and that no other family will have to endure the pain and suffering we have".

The jury found the following factors probably contributed to Lauren’s death:

  • The risk of suicide on September 16 and 17 were not properly assessed.
  • Observations levels on September 17 were not correct.
  • The circumstances of Lauren absconding from Westleigh Ward on September 16 which led to an impact on Lauren’s state of mind following the police involvement in Lilford Park on September 16, and a lack of suicide risk review at Atherleigh Park.

And the following factors possibly contributed to Lauren’s death:

  • The cycle of admissions and discharges from hospital.
  • Quality of the observations.
  • The lack of risk assessment of suicide and self-harm.
  • Failure of the anti-barricade system, all at Atherleigh Park.

There was a delay in accessing dialectical behavioural therapy (DBT) treatment for Lauren but this did not contribute to her death.

Leigh Journal:

Kind-hearted Lauren, who had lots of friends, had a love of animals which inspired her to begin studying to become a veterinary nurse.

The inquest heard Lauren’s mental health began deteriorating while in high school and was eventually diagnosed with emotional unstable personality disorder (EUPD) and clinical depression.

The jury heard that between March and September 2018, Lauren had six admissions into Atherleigh Park, ranging between four and 53 days.

Over this period, evidence was heard that there was an escalation in Lauren’s self-harm and suicide attempts.

On September 14, 2018, Lauren was detained under section 2 of the Mental Health Act at Atherleigh Park for the final time.

Lauren had been admitted following a missing person search after self-harming.

The inquest heard that while on the ward it was recorded that Lauren attempted to ligature on two occasions, attempted to abscond from the ward twice and attempted to take medication from the medication trolley.

On September 16, 2018, Lauren was able to abscond from the ward by following a doctor through a door.

The jury heard that Lauren was restrained by Greater Manchester Police and returned to the ward.

The jury were shown photographs of the bruising Lauren said she had received as a result of this restraint.

They heard Lauren had been in pain and was upset following the incident and that she had reported that the police had laughed at her and called her a “silly little girl”.

Despite the incidents on September 16, the inquest heard that while Lauren was asleep on the morning of September 17, her observations were downgraded from every 10 minutes to every 30 minutes.

It was also heard that this decision was made without awareness of all the incidents that had taken place over the weekend and without review of the records.

Evidence was heard that Lauren isolated herself on September 17 and was noted to be tearful. She was last seen on the ward at around 9.05pm.

At around 9.20pm, ward staff noticed a sheet over Lauren’s door and attempted to enter her room.

The jury heard that staff had difficulty entering Lauren’s room due to an issue with the anti-barricade door.

Lauren was found having ligatured in her room and an ambulance was called for assistance.

The inquest heard staff were not present to meet the paramedics upon arrival at the hospital site to direct them to the ward.

At the inquest, North West Boroughs Healthcare NHS Foundation Trust made a number of admissions about failures and shortfalls in the care they provided to Lauren.

HM Assistant Coroner Ms Rachel Galloway announced her intention to make a Prevention of Future Deaths Report in respect of the implementation of the observation policy and record keeping.

Alice Stevens, of Broudie Jackson Canter Solicitors, said: "This inquest has highlighted clear failures in the care afforded to Lauren in the lead up to her death.

"Lauren’s family believed that she would be safe in Westleigh Unit, yet she was able to abscond from the ward on multiple occasions and was ultimately able to take her own life.

"I hope that the trust take the Coroner’s Prevention of future Deaths Report very seriously and take steps to ensure that changes are made".

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Director of Inquest, Deborah Coles, said: "All the warning signs were there, but Lauren was failed not only by mental health services but the police, both of whom had a responsibility to keep her safe.

"The serious risks of restraint on people with mental ill health are well recognised.

"The jury highlighted the traumatising impact of Lauren’s interaction with the police as a contributory factor in her death.

"We are seeing repeated patterns of failure, ill treatment and neglect in the care of women in secure mental health settings.

"These are hospitals where women should be safe and their human rights protected.

"There is clearly a gulf between addressing the needs of women like Lauren, and the resources provided to care for them.

"To prevent future deaths it is essential that specialist, trauma-informed and women-centred treatment is available."

The trust has issued an apology to Lauren's family.

Chief operating officer at North West Boroughs Healthcare NHS Foundation Trust, John Heritage, said: “I would like to offer my sincere condolences to Lauren’s family.

"I appreciate it must be incredibly difficult to sit through a long inquest on top of losing someone you love.

“We know we made mistakes during Lauren’s care and have openly admitted these failings as part of the inquest process.

"We wholeheartedly apologise to Lauren’s family for these shortcomings and the understandable distress this has caused.

“A comprehensive investigation took place immediately after Lauren’s death and changes have been made to help minimise the risk of any similar incidents occurring in the future.

“We have strengthened our Observation, Safety and Engagement Procedure and over the coming months we are introducing an electronic system which will enable staff to use iPads to update records in real time as observations are carried out.”