Family tribute as inquest opens into Laura Davis Arbury Court death

Laura Davis died aged 22 while detained under the Mental Health Act as a patient at Arbury Court mental health hospital in Winwick.

She was found unresponsive in her bed on the women’s mental health unit – more than 120 miles from her home – in February 2017 and was subsequently pronounced dead.

A jury inquest into her death began yesterday, Monday, at Warrington Coroner’s Court, which allowed Laura’s family to speak of her kind-hearted nature.

The inquest, which is due to last for more than two weeks, is being presided over by senior coroner Jacqueline Devonish.

She explained to jurors that the function of the coroner’s court is not to attribute blame, but to establish facts surrounding the death.

Jurors were asked to answer four statutory questions, namely who the deceased person was, and how, when and where they died.

Coroner Devonish spoke of how Laura had a history of serious self-harm and had been diagnosed with an emotionally unstable personality disorder.

Originally from Devon, she grew up in Cheltenham and 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 from her family to the Townfield Lane unit, run by Elysium Healthcare Ltd.

This was originally intended as a short-term placement, but Laura remained at Arbury Court for more than three months due to delays in finding a suitable placement for her.

Her death came after she took her own life only days before she was due to be transferred to another facility for specialist treatment.

Giving evidence in person, Laura’s mother Joanne described her daughter as someone who was ‘strong morally’, and who always thought about other people before herself.

“She was generous with her emotions and everything she owned,” she said, adding that she used to look after her younger brother and twin sister, whom she thought the world of and helped with their schoolwork.

“Laura used to cover her scars before leaving the house as she did not want to look unwell and let her mental health to affect other people.”

The court heard how she was mischievous and used to speak her mind. As well as how she was clever, being a grade-A student, and wanted to become an RAF officer.

Laura Davis died at Arbury Court mental health hospital in Winwick

Laura started to become unwell aged 14, with an incident leading to a rapid behavioural change and resulting in her being ‘no longer happy or as funny and mischievous’.

Instances of self-harm increased in frequency and severity, leading to admissions to A&E and later developing into suicidal thoughts.

However, she did manage to turn her ‘rollercoaster life of happy and sad’ around again in the 12 months before her death and began to improve, before she sadly relapsed again.

A written statement prepared by Laura’s twin sister Nicola Brokenshire was also heard in court.

She described her sister as ‘super friendly and caring’, as well as a really funny person who was ‘intelligent, creative and loved animals’.

The inquest, which continues, will explore Laura’s care and treatment, her transfer to Arbury Court miles away from home, her treatment and care at Arbury Court, the events of February 20, 2017, and the emergency response when Laura was found unresponsive.

Laura’s mum Joanna previously said: “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.”

This followed a report revealing a string of failures which led to her daughter’s death.

A review by Warrington Borough Council’s safeguarding adults board was in November 2020 and raised a number of concerns over her care.

It found that, on the day of her death, Laura 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’.

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

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