Francesca Whyatt

4 CIRCUMSTANCES OF THE DEATH Francesca Whyatt was admitted to the Priory Hospital, Roehampton on 20th March 2013 under section 3, Mental health Act 1983, to its specialist Personality Disorder Unit, East Wing (thereafter known as “Emerald Ward”). The unit provided NHS commissioned services to patients requiring specialist care from all over England and Wales. Many of the patients in the Emerald Ward were at high risk of serious self-harm and all required complex and expert care. Emerald Ward was arranged over four floors (basement, ground, first and second), each separated by a single staircase. Observations of patients were primarily carried out “zonally” so that a member of staff was allocated to each floor to observe patients, save that in the case of the first and second floor, a single member of staff was allocated to undertake observations on both floors. In addition, patients were sometimes subject to closer observations (intermittent, 1:1, 2:1) where heightened risk was identified. The doors between the basement, ground and first floor were expected to be locked at all times with access granted to patients by a member of staff using a “fob” key. There was no locked door between the first and second floors. Francesca Whyatt was at known risk from ligatures. A risk assessment (“risk management self-harm plan”) was prepared shortly after her admission to the Emerald Ward indicating that she should not have tights or belts. This was because it was understood that she was more likely to self-harm with these items. On 16th April and 17th June 2013, Francesca Whyatt gained access to tights and fashioned ligatures out of them and tied them around her neck. On 6th August 2013 Francesca Whyatt used a belt cord from a dressing gown to which she had been provided access, and tied it tightly around her neck. She was discovered cyanosed and with a nosebleed. This was recognized to be a “near - miss”. This incident at least should have been treated as a serious untoward incident (SUI) and as such a formal SUI investigation should have been undertaken. The Incident Form that was used to report the incident described the level of harm as “low” and no investigation took place. On 25th September 2013 at a time between 4.05 p.m. and 4.20p.m., Francesca Whyatt was able to ascend from the basement to the top floor, through doors which were unlocked though expected to be locked, without being observed. She was then found unconscious in a lounge on the top floor of the Emerald Ward with a pair of tights around her neck secured tightly as a ligature. Attempts were made to resuscitate her at the scene. She was then taken to Kingston Hospital where she died on 28th September 2013. The medical cause of Fancesca Whyatt’s death was: 1a. Irreversible cerebral anoxia 2b. Upper airway obstruction Emerald Ward closed in June/July 2014. East Wing is now a 12 - bedded female acute mental health ward with the majority of patients diagnosed with psychosis and some are at high risk of self-harm. The NHS funds the care and treatment of the majority of the patients on East Wing through commissioning arrangements. East Wing remains a single ward arranged over four floors, with one floor now inaccessible to patients without supervision. There are no locked doors impeding access to and up the staircases between floors. There has been no risk assessment of

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