Mum backs calls for mental health inquiry to get justice for her child

A heartbroken mother whose daughter is thought to have been dead for hours in hospital before staff noticed has backed calls for a public inquiry into deaths at mental health units. Deseree Fitzpatrick died just days after being admitted to a psychiatric ward at Priory Royal Cheadle.

The 30-year-old died after breathing in her own vomit while she slept after being given medication which sedated her and suppressed her gag reflex.

She had a history of being sick in her sleep caused by a longstanding medical condition and staff were supposed to check on her condition every 15 minutes, 24 hours a day.

The inquest into her death heard that on January 23 last year staff wrote in her notes at 8:17am that she was asleep and breathing.

But 10 minutes later they found she was unresponsive, and an ambulance was called.

A pathologist told the inquest into her death that it is likely that Ms Fitzpatrick died between 4.30am and 6.30am that morning.

Coroner Andrew Bridgman said: “The observations were awfully inadequate, grossly inadequate [and that there] were times when Deseree would have been showing signs of over sedation and there were missed opportunities for this to be addressed.

“In short, Deseree died because she had been sedated to such an extent that her gag reflex was lost or suppressed allowing gastric contents to enter her lungs during sleep and this caused her death.”

Deseree’s mum Angela Porter says she cannot rest until she gets “justice” for her daughter.

She said: “The Priory said that Deseree was last checked at 8.17 and when the other carer came in at 8.20 something that she’s passed away just then. But by then she was already decomposing, her lips were blue.

“This was verified by the paramedic. He said that when he came on the scene she was already decomposing.

“How am I supposed to cope because I feel that I have not got justice for my daughter?

“She was supposed to have 15-minute checks but they were just done by someone looking through a spy-hole in the door. How the hell can you see someone take three depths of breath by looking through a spy-hole for a few seconds and not even go into the room?”

Ms Fitzpatrick had a history of mental health issues and was diagnosed with Emotional Unstable Personality Disorder.

Her mum says she was pleased to be going to The Priory to get help, but instead “they let her down”.

Ms Porter added: “People say I should put Deseree to rest but how can I when I’ve still got this hanging over my head?

“It’s not just affected me, it’s affected my two boys as well. I don’t cry in front of my kids.”

“I try to put a brave face on for them but when I’m on my own I don’t want to be here either. But I can’t do anything because I have to be here for my two boys.

“I want a public inquiry to get all of this stuff out in the open.

“I want that place closed down. I want everybody who has caused my daughter’s death to be held accountable.

“They can go home to their loved ones but I can’t go home to mine. My daughter isn’t coming home to me.

“I want anything and everything done. I want to be able to help and to be able to do something. I do want a public inquiry and I want people to be held accountable for my daughter’s death.”

In response, a Priory spokesperson said: “We want to express our sincere condolences to Deseree’s family for their loss.

“Unexpected deaths in inpatient mental health units are both tragic and extremely rare, and we ensure we learn from them and make changes so we can continue to provide a safe and therapeutic environment to some of the most complex and challenging patients in the country.

“We recognise the high demand for mental health services nationally and the urgent need for additional capacity within the NHS, which independent providers like Priory are supporting with.

“Many of the patients we support are acutely unwell with several co-morbidities, and may have been treated in multiple mental health settings before ours, and with this acuity rising year on year, we cannot overstate the need for much earlier mental health intervention, especially among young people.”

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Mental health charity Mind says deaths in secure mental health units are sadly all too common across the country so is calling for a public inquiry to investigate what is going on.

It says that the Government’s recent announcement that it is carrying out a rapid review into data on mental health inpatient units will not be sufficient.

Mind’s head of health policy and campaigns, Gemma Byrne, said: “The ever-growing reports of mistreatment and abuse in mental health inpatient settings across the country are deeply concerning.

“Over the last six months, barely a fortnight has gone by without another worrying story emerging about a mental health hospital.

“These are not isolated incidents. The only way the UK government can truly address the situation in our inpatient services is to launch a full statutory inquiry.

“While the rapid review into data on mental health inpatient settings may help with identifying failings, an inquiry is needed to get to the bottom of why these failing happen to begin with and to set out an action plan to address them.

“The UK government must launch this statutory inquiry as soon as possible, so the voices of people with lived experience and their loved ones are heard and essential systemic changes are identified.

“This must go hand in hand with long overdue investment into the inpatient workforce and estates, and crucial reforms to the Mental Health Act.”

A Department of Health and Social Care spokesperson said: “Anyone receiving treatment in an inpatient mental health facility deserves to receive safe, high-quality care and to be looked after with dignity and respect.

“We announced a rapid review into mental health inpatient settings, with a specific focus on how we use data and evidence, including complaints, feedback and whistleblowing alerts, to identify risks to safety.”

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