AN INQUEST has found that scores of basic mistakes led to the death of a ‘beautiful and intelligent’ young woman at Hollins Park Hospital.

Hannah Evans was just 22 when she died at Hollins Park, in Winwick, and a jury has delivered highly-critical findings of the steps taken to ensure the safety of the former Priestley College and Bridgewater High School student leading up to her death.

The Appleton resident had been in the hospital’s Sheridan ward for less than a day when she found hanging in a disabled toilet at 10.55pm on January 13 2015.

Warrington Guardian:

She had spent more than three months on the Weaver ward at Halton Hospital in Runcorn and a psychiatric intensive care unit at Leigh Infirmary before a transfer labelled ‘abrupt’ by an expert.

Hannah was given just two-and-a-half hour notice of her transfer despite having an ‘intensive fear of change’ and a complex history of mental health issues, and despite this no increase in observation levels was made.

The eight-day inquest, held from Thursday, March 4 to Friday, March 11, found that basic four-hourly checks were not maintained and the alarm was only raised when Hannah failed to attend for medication at 10.45pm, having been last checked at 10.30pm.

Barshaw Gardens resident Hannah was not checked for ligatures when she arrived at the hospital despite having an extensive history of keeping them secret.

It was unclear how the University of Manchester accountancy student had managed to access the toilet, which should have been locked off at all times, and unclear how she came to possess the ligature.

Warrington Coroners Court also heard that Hannah had a specific tendency to tie ligatures in bathrooms.

Hannah’s parent did not object to her transfer to the ward as they were not told about nine ligature attempts she was involved in during her time on the intensive care unit.

In a statement released following the verdict, Hannah’s family said that they were ‘devastated’ by the eight-day inquest’s findings.

They said: “Hannah was a beautiful, compassionate and intelligent young lady who repeatedly asked for help over a period of 10 years.

“We are devastated that she died in the very place she was meant to be safest.

“Our suffering has been made worse by the knowledge that her death could have been avoided if the trust had not made so many basic mistakes in caring for her.

“We feel vindicated by the jury’s careful and detailed criticisms within their conclusion.

“We will be vigilant to ensure the trust now makes the necessary changes to ensure that vulnerable patients are safe in its care.

“We would like to thank our legal team for the work undertaken on the family’s behalf.”

Selen Cavcav, caseworker at the charity INQUEST, hoped Hannah’s case would act as a catalyst for national change.

She said: “Hannah was a vulnerable young woman who had a loving family behind her who tried their very best to make sure that she was safe.

“It is a real concern that she lost her life in this way in a mental health institution with staff who were supposed to be experienced and trained to deal with her risk of suicide.

“The findings of this inquest should act as an urgent reminder to the government to make sure that services and practices in relation to mental health support for young people are improved to such a level that we don’t have another inquest conclusion highlighting basic failures in communication and risk assessment contributing to the death of another young person like Hannah.”

The family’s solicitor Gemma Vine called for an ‘urgent improvement’ in the care of young people with mental health problems.

She said: “This is yet another very sad case involving the death of a highly vulnerable young women in an adult mental health unit which could and should have been avoided.

“This case highlights not only the failings by staff on the Sheridan ward to protect Hannah but also a national problem regarding the lack of provisions in place to properly support vulnerable young women who are diagnosed with personality disorders and more wider for the large population of this country who suffer from mental health conditions.

“Her death is a shocking reminder that there needs to be an urgent improvement in the care of young people by mental health services.”

The Warrington Guardian has reached out to 5 Boroughs Partnership NHS Foundation Trust, who run the hospital, for comment.

If you have been affected by any of the issues raised in Hannah’s story call the Samaritans on 08457909090.