Before HM Coroner Lisa Milner and a jury
West Sussex Coroner’s Court
11 – 22 November 2024
Morgan Betchley was 19 years old when she died after ligaturing whilst a voluntary mental health inpatient at Meadowfield Hospital on 9 March 2023. Now an inquest has found that a series of failings and unprofessional behaviour by staff contributed to Morgan’s death.
Morgan was a young mother to a one-year old son. An aspiring architect, her family describe her as a bright, intelligent and articulate young woman with a fabulous dry sense of humour.
Morgan was autistic. She had a history of mental ill health including suicidal ideation and self-harm. Prior to February 2023, she had had a long period of stability following the birth of her son.
In the months leading up to Morgan’s death, her mental health deteriorated and in the 35 days between 1 February and her death, Morgan had two lengthy admissions to Accident and Emergency, four different mental health bed admissions including three detentions under section 2 of the Mental Health Act, and spent a day in police custody.
Morgan was admitted to Meadowfield Hospital, run by Sussex Partnership NHS Foundation Trust (SPFT), three times: from 13 to 21 February; from 25 to 27 February; and from 3 March until her death.
During her first admission to Rowan Ward at Meadowfield Hospital, Morgan was found with ligatures and to have self harmed on multiple occasions. Many of these were not recorded as risk events by staff.
On 20 February, Morgan’s consultant psychiatrist decided to rescind Morgan’s detention under the Mental Health Act and direct her discharge without consulting her family.
Within 24 hours of discharge, Morgan had been assessed by the crisis team who determined that she needed to return to hospital and so she was taken back to A&E. Morgan was again detained under the Mental Health Act and transferred to Maple Ward at Meadowfield Hospital on 25 February 2023. The following day, she was found with a ligature.
On 27 February, Morgan was restrained by staff, during which members of ward staff suffered injuries. In response, Morgan’s consultant psychiatrist discharged her from detention under the Mental Health Act and recorded that she could only remain on the ward if she signed a behavioural contract.
Morgan left the ward and ligatured in the grounds of the hospital. The police attended and Morgan was arrested and taken to police custody, where she remained for 24 hours after which she was again detained under the Mental Health Act and transferred back to A&E.
Morgan was eventually taken back to Rowan Ward at Meadowfield Hospital as a voluntary patient on 3 March. The inquest heard evidence that Morgan provided a letter of apology to staff about events that occurred on Maple Ward but that staff did not consider this to be genuine.
Her family wrote to the hospital during the admission to express their concerns about the two unsafe discharges that had taken place in previous days and seeking to work with staff to support Morgan and assist with understanding her needs as an autistic young woman.
In their first meeting with Morgan’s consultant psychiatrist on 7 March, the family were told that this letter had caused a breakdown in the therapeutic relationship with staff.
On the evening of 9 March, all four staff working on the ward described the ward as very disrupted, including two staff being engaged in restraining another patient almost constantly from 9.30pm. The inquest heard evidence that Morgan reported to staff that she was feel anxious about impending discharge.
At around 10.20pm, a nurse on the ward asked her to remain in the communal areas and removed Morgan’s belongings, including her bedding, recording that this was done to ensure her safety was not compromised.
A few hours later, Morgan asked a member of staff for some of her belongings to be returned. These were given back to her following a passing interaction. Within half an hour, Morgan was found having ligatured in her bedroom. She was pronounced dead soon after.
The jury found that there were repeated failures by staff at Meadowfield Hospital to follow policies and procedures and that there were “failures relating to admission process, understanding of existing diagnoses, risk management, record keeping, family involvement and discharge planning” which “prevented Morgan from receiving access to services she needed at the time”.
The jury also found that Morgan’s attempt to apologise “was not handled in a professional manner by senior staff members of Rowan Ward, leading to a fractured therapeutic relationship” and that “the situation was made unnecessarily stressful for Morgan.”
Speaking after the inquest, Morgan’s family said: “The past two weeks have been gruelling for us as a family. We would like to thank the jury for the diligence and care they have taken. Morgan did not receive that care in the last few weeks of her life so she deserved it after her death.
Everything we feared about Morgan's treatment under Sussex Partnership has been confirmed. She was systematically and repeatedly failed by those who were supposed to keep her safe. There was a total disregard for her history of trauma and that she was a young autistic mother.
The merry go round of admissions and discharges, with no planning at all and whilst being treated in such a punitive way, retraumatised Morgan and caused a complete and catastrophic deterioration in her mental state.
As a family, we tried to tell the professionals about Morgan and asked to work collaboratively with staff yet we were characterised as troublemakers.
In the height of her distress, Morgan harmed some of the staff involved in her care. She was devastated by this and wrote a letter of apology.
This was repeatedly dismissed by staff, including the consultant psychiatrist, as insincere and it led to staff withdrawing from providing her with therapeutic care, despite being responsible for keeping her safe. We are still struggling to understand how mental health professionals could have treated Morgan in this way.
It is with very heavy hearts that we listened to ward staff justify their treatment of Morgan and refused to reflect on, or accept, any failings in her care and indeed, we were told that staff felt they had provided "excellent care" to Morgan. That is clearly not the case. Until there is proper accountability and reflection, it is very difficult to have faith that there will be any meaningful change for people like Morgan.”
Selen Cavcav, Senior Caseworker at INQUEST, said: "The failures in this case has been staggering. Those who have a genuine desire to end deaths in mental health settings should go through the evidence with a fine toothcomb to understand exactly how a young autistic woman who had all the fight in her to get better should not be treated.
We welcome the jury’s findings in this case and the insight that they have provided to what happened to Morgan and how things could have been done better.
This trust has a concerning track record of preventable deaths and knows all too well that their empty platitudes will not save lives. What needs to happen is a proper culture shift on the ground.”
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Leila Hagmann on [email protected].
The family are represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bhatt Murphy and Jessica Elliott of one Crown Office Row. They are supported by INQUEST Senior Caseworker Selen Cavcav.
Other Interested persons represented are Sussex Partnership Foundation Trust, University Hospitals Sussex NHS Foundation Trust and West Sussex County Council.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Deaths in the care of Sussex mental health services:
- Morghana Woodburn, 18, died a self-inflicted death at Meadowfield Hospital in January 2018. Morghana was diagnosed with PTSD and EUPD. She was moved seven times between four different hospitals over the nine months leading up to her death. An inquest concluded that she died as a result of her mental health issues which led her to self-harm. Media coverage.
- Ellame Ford-Dunn, was 16 years old when she died after absconding and ligaturing whilst a mental health inpatient at Worthing Hospital. An inquest into her death was adjourned earlier this year. Media release.
- Matty Sheldrick, a 29 year old autistic person, died on 22 November 2022 after ligaturing outside the Royal Sussex County Hospital. They had left A&E less than two hours before. An inquest into their death resumed this week. Media release.
- Jason Pulman, a 15 year old transgender teenager died a self-inflicted death on 19 April 2022 in East Sussex. An inquest found that systemic failures by all of the organisations involved in his care, with the exception of his school, possibly contributed to his death. Media release.
- Jessie Eastland Seares, 19, died whilst an inpatient at Mill View Hospital in May 2022. Jessie was autistic and had a complex history of neurodevelopmental, physical and mental health issues. A jury found that systemic failures in health and social care led to her death. Media release.
- Rachel Garrett, 22, died after falling from a height in Brighton on 29 July 2020. An inquest found that opportunities to save her life had been missed. Rachel had mental and physical health needs and had spent time in the care of Mill View Hospital. Media release.
- The Telegraph reported in January 2022 that more than 360 patients took their own lives after being treated by Sussex Partnership Foundation NHS Trust in the past five years. While there were also 15 coroner’s reports to prevent future deaths.
- Bethany Tenquist, 26, died after ligaturing in her room at Mill View Hospital on 16 January 2019. An inquest found a sequence of serious failures relating to staffing, leadership and safeguarding processes on ward probably had a direct causal connection to her death. Media release.
- Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care. Media release.
- In 2016, local media reported that five women had died at Mill View Hospital, including Janet Müller (above), Danuta Corbett, Jessica Philpott, Jackie Stansby, and Philippa Mortiz-Parsons.
- Sabrina ‘Sabby’ Walsh, 32, died on the Woodlands Ward in Sussex 2016. The inquest found gross failures and neglect contributed to her death. Media release.
- Bethan Smith, 31, died whilst under the care of Sussex Partnership Trust in 2011. Her mother wrote this about their experiences.
Morgan-rose Betchley
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
Before HM Coroner Lisa Milner and a jury
West Sussex Coroner’s Court
11 – 22 November 2024
Morgan Betchley was 19 years old when she died after ligaturing whilst a voluntary mental health inpatient at Meadowfield Hospital on 9 March 2023. Now an inquest has found that a series of failings and unprofessional behaviour by staff contributed to Morgan’s death.
Morgan was a young mother to a one-year old son. An aspiring architect, her family describe her as a bright, intelligent and articulate young woman with a fabulous dry sense of humour.
Morgan was autistic. She had a history of mental ill health including suicidal ideation and self-harm. Prior to February 2023, she had had a long period of stability following the birth of her son.
In the months leading up to Morgan’s death, her mental health deteriorated and in the 35 days between 1 February and her death, Morgan had two lengthy admissions to Accident and Emergency, four different mental health bed admissions including three detentions under section 2 of the Mental Health Act, and spent a day in police custody.
Morgan was admitted to Meadowfield Hospital, run by Sussex Partnership NHS Foundation Trust (SPFT), three times: from 13 to 21 February; from 25 to 27 February; and from 3 March until her death.
During her first admission to Rowan Ward at Meadowfield Hospital, Morgan was found with ligatures and to have self harmed on multiple occasions. Many of these were not recorded as risk events by staff.
On 20 February, Morgan’s consultant psychiatrist decided to rescind Morgan’s detention under the Mental Health Act and direct her discharge without consulting her family.
Within 24 hours of discharge, Morgan had been assessed by the crisis team who determined that she needed to return to hospital and so she was taken back to A&E. Morgan was again detained under the Mental Health Act and transferred to Maple Ward at Meadowfield Hospital on 25 February 2023. The following day, she was found with a ligature.
On 27 February, Morgan was restrained by staff, during which members of ward staff suffered injuries. In response, Morgan’s consultant psychiatrist discharged her from detention under the Mental Health Act and recorded that she could only remain on the ward if she signed a behavioural contract.
Morgan left the ward and ligatured in the grounds of the hospital. The police attended and Morgan was arrested and taken to police custody, where she remained for 24 hours after which she was again detained under the Mental Health Act and transferred back to A&E.
Morgan was eventually taken back to Rowan Ward at Meadowfield Hospital as a voluntary patient on 3 March. The inquest heard evidence that Morgan provided a letter of apology to staff about events that occurred on Maple Ward but that staff did not consider this to be genuine.
Her family wrote to the hospital during the admission to express their concerns about the two unsafe discharges that had taken place in previous days and seeking to work with staff to support Morgan and assist with understanding her needs as an autistic young woman.
In their first meeting with Morgan’s consultant psychiatrist on 7 March, the family were told that this letter had caused a breakdown in the therapeutic relationship with staff.
On the evening of 9 March, all four staff working on the ward described the ward as very disrupted, including two staff being engaged in restraining another patient almost constantly from 9.30pm. The inquest heard evidence that Morgan reported to staff that she was feel anxious about impending discharge.
At around 10.20pm, a nurse on the ward asked her to remain in the communal areas and removed Morgan’s belongings, including her bedding, recording that this was done to ensure her safety was not compromised.
A few hours later, Morgan asked a member of staff for some of her belongings to be returned. These were given back to her following a passing interaction. Within half an hour, Morgan was found having ligatured in her bedroom. She was pronounced dead soon after.
The jury found that there were repeated failures by staff at Meadowfield Hospital to follow policies and procedures and that there were “failures relating to admission process, understanding of existing diagnoses, risk management, record keeping, family involvement and discharge planning” which “prevented Morgan from receiving access to services she needed at the time”.
The jury also found that Morgan’s attempt to apologise “was not handled in a professional manner by senior staff members of Rowan Ward, leading to a fractured therapeutic relationship” and that “the situation was made unnecessarily stressful for Morgan.”
Speaking after the inquest, Morgan’s family said: “The past two weeks have been gruelling for us as a family. We would like to thank the jury for the diligence and care they have taken. Morgan did not receive that care in the last few weeks of her life so she deserved it after her death.
Everything we feared about Morgan's treatment under Sussex Partnership has been confirmed. She was systematically and repeatedly failed by those who were supposed to keep her safe. There was a total disregard for her history of trauma and that she was a young autistic mother.
The merry go round of admissions and discharges, with no planning at all and whilst being treated in such a punitive way, retraumatised Morgan and caused a complete and catastrophic deterioration in her mental state.
As a family, we tried to tell the professionals about Morgan and asked to work collaboratively with staff yet we were characterised as troublemakers.
In the height of her distress, Morgan harmed some of the staff involved in her care. She was devastated by this and wrote a letter of apology.
This was repeatedly dismissed by staff, including the consultant psychiatrist, as insincere and it led to staff withdrawing from providing her with therapeutic care, despite being responsible for keeping her safe. We are still struggling to understand how mental health professionals could have treated Morgan in this way.
It is with very heavy hearts that we listened to ward staff justify their treatment of Morgan and refused to reflect on, or accept, any failings in her care and indeed, we were told that staff felt they had provided "excellent care" to Morgan. That is clearly not the case. Until there is proper accountability and reflection, it is very difficult to have faith that there will be any meaningful change for people like Morgan.”
Selen Cavcav, Senior Caseworker at INQUEST, said: "The failures in this case has been staggering. Those who have a genuine desire to end deaths in mental health settings should go through the evidence with a fine toothcomb to understand exactly how a young autistic woman who had all the fight in her to get better should not be treated.
We welcome the jury’s findings in this case and the insight that they have provided to what happened to Morgan and how things could have been done better.
This trust has a concerning track record of preventable deaths and knows all too well that their empty platitudes will not save lives. What needs to happen is a proper culture shift on the ground.”
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Leila Hagmann on [email protected].
The family are represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bhatt Murphy and Jessica Elliott of one Crown Office Row. They are supported by INQUEST Senior Caseworker Selen Cavcav.
Other Interested persons represented are Sussex Partnership Foundation Trust, University Hospitals Sussex NHS Foundation Trust and West Sussex County Council.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Deaths in the care of Sussex mental health services:
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