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Jury concludes failings contributed to death of secure patient Janet Müller who absconded from Mill View Hospital

16 June 2017

Before HM Senior Coroner Penelope Schofield
West Sussex Coroners Court
5 June – 15 June

Janet Müller, 21, was killed after absconding from Mill View Hospital where she was detained under the Mental Health Act for her own safety.  On 15 June 2017, the inquest into her death concluded. Hers was one of a number of concerning recent deaths of inpatients on the ward, which is run by Sussex Partnership NHS Foundation Trust.

Janet was suffering from her first psychotic episode at the time of her death. She absconded from the ward twice on the 12 March 2015. Tragically, the second time she went missing she did not return and the following day her burnt body was discovered in an abandoned car. A man not previously known to Janet was convicted of her manslaughter in February 2016.

The jury found that there were a number of failings in Janet’s care, including:
• A lack of communication regarding her risk of absconding
• Incomplete, insufficient and at times contradictory nursing records, handovers, risk assessment and care plan
• A failure by hospital administration to provide sufficient staff
• A lack of urgency in replacing the garden fence, which was acknowledged to be inadequate.

Over the 10 days that Janet was in hospital, she repeatedly told staff that she wanted to leave. On 12 March 2015, Janet absconded from the ward at some point after 7.45am, but despite being on 15 minute observations, the senior nurse on the ward was not informed, and a search was not instigated for over an hour. Janet later told staff that she had left by climbing over the garden wall.
She had been found in a field by a member of the public in a very distressed state and was returned to the ward by the police. A recommendation by a senior manager that Janet should be placed on constant observations and that the door to the garden should be locked was not heeded by staff on the ward and instead, Janet was allowed into the garden on her own and there is no evidence that she was observed more frequently than every hour until 8pm that evening.

At around 9pm, Janet became very distressed. Despite this, her level of observations was not increased and no steps were taken to ensure that Janet remained on the ward. Janet was identified as missing at 10.15pm that night and her body was found the next day.

It was confirmed at the inquest that the Trust had been aware of the risks posed by the low garden wall which enabled Janet’s leave since at least 2011, including from patients escaping over the wall and from men entering the women-only ward, but had failed to increase the height of the wall sufficiently until after Janet’s death.


In a statement, Janet’s mother, Ramona Müller said: “Janet was a beautiful and bright young woman with a life full of possibilities ahead of her. We mourn for Janet today as we do everyday. She was unwell and needed the hospital and Sussex Partnership NHS Foundation Trust to take good care of her. Instead of that, Janet’s last few days were a nightmare. As a family, we are concerned that even now, the Trust has not learnt the underlying lessons from Janet’s death.
We are disappointed that the questioning of witnesses by the Trust’s legal representatives was designed to minimise the issues in Janet’s case and to protect the hospital, not to respect Janet’s human rights.  The Trust knew for at least 3 years that patients were escaping over the garden wall and it should not have taken Janet’s death for action to have been taken. Janet’s death could have been prevented.”

Deborah Coles, Director of INQUEST, said: Yet again, we see another vulnerable young woman being failed by the very people who should have been there to protect her.  Although she was tragically killed by a stranger, the failures in Janet’s care were not isolated incidents.  The same trust has suffered serious criticism before in relation to previous deaths, which begs the question had they acted on previous recommendations would Janet still be alive today?” 

Charlotte Haworth Hird, Janet’s family’s solicitor, said: “The failings in Janet’s care are depressingly familiar: inadequate risk assessments, poor record keeping and communication, a failure to respond promptly to known risks, and a failure to keep a vulnerable young woman safe. It is simply not good enough for Trusts to keep saying that changes have been made and lessons have been learnt when it is clear that this is not enough. Until there is proper investment in our mental health services and patient safety is considered a priority, these patient deaths will continue”. 


The family is represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bindmans Solicitors and barrister Kirsten Heaven of Garden Court chambers.
ENDS


NOTES TO EDITORS
For further information, please contact Lucy McKay on 020 7263 1111 or lucymckay@inquest.org.uk

1. Coroners have previously raised concerns about the ward and Sussex Partnership NHS Trust in a number of Prevention of Future Death reports including the following:
Ms Corbett, who died while on escorted leave from Meadowfield.
Ms French, who was discharged early from Meadowfield prior to her death.
Mr Shillinglaw, who died in another Sussex Partnership NHS Trust ward. Concerns were also raised about risk assessment.
NOTE: please do not report full names of the deceased from these reports.

2. We are aware of a number of other deaths relating to the same ward, as reported in local press.

3. Christopher Jeffrey-Shaw was convicted of the manslaughter of Janet in February 2016.

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths. Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.

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