“I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes.
Eight weeks later, Brooke took her own life.
“I thought she would be well looked after, would recover and be able to get on with her life. I can’t get over that,” Darbon said.
The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that she had been placed on 24-hour observations, Brooke would not have died.
Brooke, who was autistic, wanted to become a vet. Darbon remembers her as “very caring, thoughtful and sensitive.” But she was also troubled. She had a history of self-harm and suicide and had first come under the care of NHS child and adolescent mental health services at the age of 12.
In 2018 she was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specializes in treating personality disorders.
After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch.
But then the adolescent’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital.
After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice – a legal warning that details changes that must be made to stop other people dying in the same circumstances. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge.
It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room for her after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards.
“[Handling potential ligatures] would and should have resulted in a full risk assessment and search of her room, that would have resulted in an increase in her level of observations to 1:1 observations,” the jury concluded. “Brooke Martin, if constantly observed or other safety measures put in place, would not have been able to tie the ligature that caused her death of her and would not therefore have died on 11 June 2019.”
Paul Martin, Brooke’s grandfather, said: “What happened was so fundamental in error, negligence, that it defies logic. How could a company that is supposed to care for vulnerable people be so negligent?”
Brooke is not the only inpatient to have died at an Elysium mental health facility. The charity Inquest represents six other families with loved ones who have died since 2016 while in their care.
The quest into the death of 16-year-old Nadia Shah in an Elysium unit in Hertfordshire in 2019 found similar failings to Brooke’s case: delayed observation and access to ligatures – a dangerous combination. Nadia’s death was due to “misadventure, contributed to by the inadequate care at the Potters Bar clinic”, the jury said.
Elysium Healthcare said it had sent its deepest condolences to Brooke’s family and friends over “this tragic incident”. It reiterated what it said when the inquest concluded last July, which was that after her death it had immediately taken “significant steps” to improve patient safety at Chadwick Lodge.
It also pledged to reflect and “implement where required … further learning as a result of the inquest … [to] ensure that our policies and procedures are as effective and as responsive as they can be in the provision of care for highly vulnerable people.”