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A mother whose daughter was neglected by a hospital before she took her own life, blamed the ‘failures of the system’ for the death of her daughter and demanded improved care for future patients.
The court documents show that Iona Imogen Lee’s suicide is one of at least five deaths that failures at Derbyshire’s mental health units have caused or contributed to it over the past decade. The health and social care regulator is currently reviewing information about three deaths in the units.
Morag Lee, 57, opened over her ‘inspirational, friendly, beloved’ daughter iona’s heartbreaking last hours at the Hartington unit at the Chesterfield Royal Hospital in Chesterfield, before the 24-year-old was transferred to the ICU where she died on September 18, 2023.
The 57-year-old, Van Derby, has with The independent After a precursor in January ruled that her child died by ‘suicide contributed by neglect’ on the hall where she was detained on September 15, 2023 under the Mental Health Act.
Ms Lee said: ‘The investigation of the death of Iona was a devastating experience, which revealed the tragic failures of the system that directly contributed to her passing.
“I’m still trying to get my head around, that’s what still wakes me up all night – and realizing how much chaos around her was and how little support she got and how disregarded was that she was in her last few hours, which destroyed me. She had to go through it on her own at the place where she should have been safe. ‘
The Care Quality Commission (CQC) has conducted several inspections since 2023 due to concerns raised and incidents, including death, at the Hartington Unit and the Radbourne Unit, at Royal Derby Hospital in Derby. The divisions were the two inpatient units for adult mental health units in the working age under the Derbyshire Healthcare NHS Foundation Trust until the services of the Hartington unit were transferred to the New Derwent unit last month.
The regulator said the latest inspection showed that the presenter worked hard to reduce risks, so that the conditions placed on the trust were removed, with the rating of the services increased to ‘well’ – but the CQC confirmed that it is currently reviewing information about three deaths at the units.
The trust apologized for its failures in Iona’s care, with “significant improvements” that have been taking over its acute inpatient facilities over the past few years.
It was found during the investigation of the Iona death in January that “there were a series of errors in planning, management and implementation of Iona’s observations after admission” and that “instruction, information and supervision were all inadequate, just like the primary induction”.
The jury concluded that Iona’s level of observation should have been increased to be kept in the staff’s eyesight, but due to the shortage of staff on the hall, she was only reviewed. Even then it must have been at least every 15 minutes, but the 24-year-old was found only 43 minutes after she was last seen.
Ms Lee said: “It is heartbreaking to know that she has been left unnoticed for so long, and the thought of her last 43 minutes, alone, is unbearable.”
She raised “serious concern” about the management of the Hartington unit and believes that the blame also lies with this and previous governments in their role overseeing a crippled NHS.
The investigations over the past ten years have identified failures by the units in Hartington and Radbourne that have caused or contributed to at least five deaths, including wrong decisions about patients who have been granted or dismissed from the wards, unlawful prescription of medication and insufficient risk assessment. A Coroner who issues a warning to the policy change trust for fear of future deaths.
Ms. Lee called on future patients: “The hospital has changed their policy over the past year, but the lead was in place that was not followed two years ago and led to the death of my daughter – so how do we know that what will be in place will continue to be implemented? What reassurance has the public?”
In January, the Health Services Safety Investigations Body (HSSIB) expressed concern that the healthcare system “does not learn” due to safety examinations that occur after a person died during or shortly after care during a stay in a mental health facility.
Mark Powell, CEO of Derbyshire Healthcare NHS Foundation Trust, said: ‘I apologize to Iona’s family and regret deeply about the pain and distress they experienced.
“Our services are aimed at maintaining the highest standards for patient safety, with trauma -informed therapeutic care. We are investigating all incidents thoroughly and are committed to learning from internal and external reviews, HM Coroner and feedback recommendations and caregivers to ensure that we learn and continuous improvements to our services.”
He continued: ‘I offer my deepest condolences to those who unfortunately lost a family member while in our care. I am very sorry for any learning that indicates that there was a failure in the services that were previously rendered. “
He added that two new units open this spring, which offers improved privacy, dignity and safety functions.
A spokesman for the Department of Health and Social Care said: ‘This government has inherited a broken NHS and it is unacceptable that patients with mental health did not receive the care and treatment they earn.
“We are reforming the Mental Health Act, so that patients are treated with dignity and respect, recruit 8,500 more mental health workers and publish a refreshing workforce plan to ensure that the NHS has the right people, also in mental health environments, to provide the care that patients need.”
If you are experiencing feelings of distress, or struggle to head, you can talk to the Samaritans, with confidence, at 116 123 (UK and ROI), e -mail jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch.
If you are based in the US, and you or someone you know, you need to need, call or SMS 988 at the moment, or visit 988lifeline.org To access online chat from the 988 suicide and crisis life line. It is a free, confidential crisis hotline that is available for everyone 24 hours a day, seven days a week. If you are in another country, you can go www.befrienters.org To find a helpline near you
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