‘Totally Contradictory Understanding Of Policy’ Led To Death Of Essex Mum, Michelle Morton, In Colchester Hospital, Inquest Finds
An inquest into the death of Michelle Morton has returned an open verdict with a narrative conclusion citing multiple failings before her death on December 8th 2019. The inquest, at Essex Coroner’s Court, Chelmsford, heard by a jury and presided over by coroner Sean Horstead, highlighted a totally contradictory understanding of policy regarding access to the garden, allowing Michelle to walk unsupervised in a dark garden. The conclusion also highlighted several further important failings contributing to her death:
- Failure to perform health and safety checks
- Lack of observations and communication, not taking into account Michelle’s condition
- Inadequate staffing levels, below those authorised by the Trust
- Inadequate staff training, particularly around awareness of potential ligature points
Michelle died while she was being treated as an inpatient in the Ardleigh Ward at The Lakes Mental Health Hospital in Colchester after being sectioned under the Mental Health Act earlier in 2019. Michelle had been a patient on the Ardleigh Ward since September 2019, and tragically, she was due to be discharged on December 13th, just four days after her death.
For several years before her admission to hospital, Michelle had suffered from poor mental health and had been diagnosed with Emotionally Unstable Personality Disorder (EUPD) – a condition that can cause extreme highs and lows of emotion.
Michelle Morton’s sister, Joanna, said: “While nothing can ever fill the hole in my life that Michelle’s death left, today’s verdict gives our family a chance to start the healing process. My little sister was failed by those who should have kept her safe. The care Michelle received from the Essex Partnership University NHS Foundation Trust (EPUT) was substandard and the Trust must learn lessons from her death. Michelle was a loving mother to her daughter and those responsible for her death will never understand the pain her little girl will always feel.
“Far too often families and vulnerable people have been failed by mental health care in Essex, and I back the calls for a Statutory Independent Inquiry into services in the county. The current inquiry is too weak and will not hold to account those responsible for the death of Michelle and many other family’s loved ones. After almost three years we finally have answers about the circumstance of Michelle’s death and we are grateful to everyone who has supported us during this time. I now ask the media to respect the privacy of our family and allow us time to heal.”
Nina Ali, Partner and Medical Negligence Solicitor at Hodge Jones & Allen, representing the family, said: We are pleased the jury has returned an open, narrative verdict detailing the multiple failings Michelle was exposed to in the run-up to her death. It is clear that the care provided to Michelle Morton was lacking and safeguarding procedures were not robust enough. In particular, the total lack of understanding regarding the access policy to the garden, allowing Michelle to walk alone in total darkness is shocking. The inquest heard how something as simple as a locked door could have prevented this tragedy. When added to a lack of awareness as to potential ligature points, poor staff communication, and lack of supervision, it is clear Michelle was failed.
“Today’s conclusion marks another sad chapter in the state of mental health care in Essex. Michelle’s death is yet another tragedy from Essex’s mental healthcare system – and lessons must be learned. It is clear to me and many of the families failed in the county that our current processes and proceedings aren’t enough. These failings cannot, they must not go on.
“The families we represent keep asking the Government for the current inquiry, led by Dr Geraldine Strathdee, to be changed to a Statutory Inquiry to compel people to give evidence and to bring about real improvements to this failing care system. Our families deserve accountability, not empty words and recommendations that get ignored – and I implore the government to upgrade the inquiry.”