A REPORT has revealed a string of failures which led to the death of a patient at a mental health hospital.

Laura Davis, an inpatient at Arbury Court in Winwick, was found unresponsive in her bed on the women’s mental health unit in February 2017 and was subsequently pronounced dead.

The 22-year-old had a history of serious self harm and had been diagnosed with an emotionally unstable personality disorder, having been a victim of sexual abuse.

Ms Davis, who was originally from Devon and grew up in Cheltenham, was admitted to Wooton Lawn Hospital in Gloucestershire in June 2016.

In November that year, the ‘hard working and high achieving student’ was moved 120 miles away to the Townfield Lane unit – where she remained for more than three months until her death, only days before she was due to be transferred to another facility for specialist treatment.

Warrington Guardian:

Arbury Court

A review into Ms Davis’ suicide by Warrington Borough Council’s safeguarding adults board was published this week and raised a number of concerns over her care.

It found that, on the day of her death, the RAF hopeful was granted ‘unsupervised use of problematic materials’ which she then used in order to take her own life.

Efforts to transfer her to a ‘more suitable placement’ were ‘hampered by the scarcity of suitable placement options’ and the failure of agencies involved in her care to share information.

‘Widespread issues’ were found in the recording of risks to Ms Davis’ safety, as were ‘missed opportunities for independent scrutiny’.

She was described by her family as a ‘very caring and intuitive’ woman who ‘always put others before herself’.

Mum Joanna added: “I am devastated by Laura’s death – I believe that she was badly let down both by Wotton Lawn, who sent her so far away from home, and by Arbury Court, where she eventually died.

“After such a long wait for answers, I am pleased that the safeguarding adults board’s investigation has highlighted some of the serious failures in her care.

“I am now looking towards the inquest into Laura’s death, where I hope to finally obtain answers from those responsible for her care as to how her tragic death was allowed to happen.”

The report made a total of eight recommendations directed at various agencies, including NHS England.

Joseph Morgan, of legal firm Bindmans LLP and who is representing Joanna Davis, said: “The findings of the safeguarding adults review reveal numerous failures in Laura’s care, both in terms of the catastrophic decisions that led to her death and the wider management of her care by all agencies involved.

“Her case highlights the widespread issues across mental health services regarding failures in risk assessments, failures in record keeping and information sharing and the inadequate provision of suitable placements.”

Selen Cavcav – senior caseworker at Inquest, a charity which is supporting the family – added: “Behind so many deaths of young women in mental health care there is a history of sexual abuse and complex mental health needs.

“So many people in need end up waiting for months, if not years, for a suitable placement.

“Long waiting lists and lack of suitable services is simply costing lives.

“Three years on from Laura’s death, this review is making some bold criticisms and strong recommendations which we hope will be implemented without any further delay.”

Gloucestershire Health and Care NHS Foundation Trust, which arranged Ms Davis’ placement, says it is ‘committed to learning from her tragic death’.

Director of nursing, therapies and quality John Trevains said: “Firstly, we would like to express our deepest sympathies to Laura’s family.

“While, sadly, we cannot change the outcome for them we are committed to learning from Laura’s tragic death.

“We have carried out our own serious incident review into what took place and the learning from that, as well as the outcome of the safeguarding adults review, is being embedded into our processes, systems and training to ensure that, wherever possible, such tragic events do not take place again.”

A WBC spokesman said: "The council is aware that the summary findings of a safeguarding adult review commissioned and completed by Warrington safeguarding adults board - a partnership made up of the council, the clinical commissioning group, police and many other public and third sector agencies - has now been published, and we would like to express our condolences to the family and friends of Laura.

"The purpose of a SAR is described in the Care Act 2014 as to promote effective learning and improvement action to prevent future deaths or serious harm occurring again - the purpose of a SAR is not to hold any individual or organisation to account, the aim is that lessons can be learned from the case and for those lessons to be applied to future cases to prevent similar harm recurring.

"The safeguarding adults board is currently finalising a local action plan to address the issues and recommendations found as a result of the review."

A spokesman for Elysium Healthcare, which runs Arbury Court, added: “We are regretfully not in a position to comment on this tragic case until the conclusion of the formal inquest, at which point we will make a full statement.”

If you have been affected by the issues raised in this article, call the Samaritans for free on 116 123.