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Jury finds multiple failures lead to the death of 18 year old Rebecca Louise Overy who was moved from adolescent into adult mental health care without proper transitional arrangements
28 November 2014
A jury has delivered their critical conclusions regarding the death of Rebecca Louise Overy who died on the 24th June 2013 at the Queens Medical Centre, Nottingham. Rebecca was 18 years old when she was found unresponsive with a ligature in her room at Annesley House – an adult secure unit. She was a sectioned patient at the time of her death and was allegedly on 5 minute observations due to the fact that she was deemed a suicide risk. After her death it became apparent that during the first six weeks of her admission she had approximately 40 incidents of self harm.
The inquest has addressed issues around Rebecca’s transition to adult services and has considered whether more measures could have been put in place to safeguard her. It also focused on the quality of care she received at Annesley House and the adequacy of her observations on the night she was found.
Rebecca had been in a secure adolescent psychiatric unit from the age of 13 years where she had an established network of support and friends of her own age. Her mother described her as being a bubbly teenager. She had posters in her room and enjoyed making jewellery. She had enrolled in an animal care course and had planned to do some voluntary work. Her doctors were very encouraging and led her to believe that she had a future. Rebecca believed that she would be returning back home after she turned 18. Instead a day after she turned 18 she was moved to an adult mental health facility. Her mother stated that her spark disappeared and she became despondent.
The Jury found that Rebecca’s long history of suicide and self harm escalated after her speedy transition to adult mental health care without proper planning, cancellation of visits and tight restrictions. Her observations were also reduced from constant to every five minutes which they stated gave her the window of opportunity to prepare a ligature.
Her Majesty’s Assistant Coroner Ms Stephanie Haskey will also be making a Prevention of Death Report to the Department of Health, addressing in particular the transfer of adolescents into adult units and the lack of provisions for the care of young people aged 18-24.
Rebecca’s mum Kathryn Wilson and her step father Barry Wilson said:
“Following the inquest into Rebecca's death the healthcare professionals have all moved on with their lives, but we will not. Obviously, it will be great if they do learn lessons AND implement changes so that no young person has to die unnecessarily whilst in care. Unfortunately, for us they obviously had lessons to learn so they took away our beautiful daughter, our future family, our future grandchildren and our world will always be a darker place because of what they did NOT do for our precious Rebecca.”
Gemma Vine, solicitor representing Rebecca’s family said:
“This is a very sad case involving the death of a highly vulnerable young woman in an adult mental health unit which could and should have been avoided. This case highlights not only the failings by staff at Annesley House to protect Rebecca, but also a national problem regarding the lack of provisions in place to properly support vulnerable young adolescents, who once they turn 18 are thrust from adolescent care into adult care.”
Deborah Coles, co-director of INQUEST said:
“Rebecca’s death is a shocking reminder that there needs to be an urgent improvement in the care of children and young people by mental health and social services, which is currently not working and letting down many vulnerable young people and their families. Rebecca was failed by the very services that should have provided her with care and treatment at a most critical time in her life. It is absolutely unacceptable that she was placed in an adult mental health facility with no transitional arrangements. Family visits were often cancelled and there were serious problems in relation to the sharing of information between the family and those who were in charge of her care.”
INQUEST has been working with the family of Rebecca Overy since April 2014. The family is represented by INQUEST Lawyers Group member Gemma Vine from Lester Morrill Solicitors and Ian Golsdstack from St Johns Buildings.
For further information, please contact: Selen Cavcav on 020 7263 1111.
‘The decision to publish the Cass report is an extraordinary victory for INQUEST… Belatedly, it lifts another layer of camouflage from the secrets, lies and impunity that prevail in large sections of the British state and make such terrible events not merely possible but more likely…What INQUEST, Celia Stubbs and countless others around the world – say, the Mothers and Grandmothers of the Disappeared in Argentina – keep reminding us is not just that the instincts of the powerful are wrong, but that they can also be defeated, however long it may take.’
– David Ransom, friend of Blair Peach and former editor of New Internationalist magazine