An 18-year-old patient with ADHD and autism, Morgan-Rose Hart, tragically lost her life due to neglect at an NHS mental health unit, according to an inquest jury. The incident occurred at the Derwent Centre in Harlow, Essex, where Ms. Hart was found unresponsive in July 2022. The inquest revealed that staff had falsified observations and failed to carry out critical checks, leading to the fatal outcome. The Essex Partnership University NHS Foundation Trust (EPUT), responsible for the unit, has acknowledged the need for learning from this tragedy.
On the day of the incident, Ms. Hart had informed the staff that she was going to take a shower. The staff members carried digital tablets with an alarm system to monitor the time spent by patients in the bathroom. Shockingly, Ms. Hart’s alarm was deactivated after only 21 seconds, and no one checked on her. It took nearly an hour before she was finally checked on, at which point she was unresponsive. Sadly, she passed away a week later at Princess Alexandra Hospital in Harlow.
During the inquest, it was uncovered that the staff at EPUT failed to conduct regular face-to-face checks on Ms. Hart. In fact, three employees admitted to falsifying observation notes from the day of the incident. These breaches of basic protocol contributed to the tragic outcome.
Michelle Hart, the mother of the deceased patient, expressed her grief and called for healthcare professionals involved in her daughter’s care to learn from their mistakes. She described her daughter as a compassionate and humorous person with a profound love for animals and wildlife. In response, Paul Scott, the chief executive at EPUT, issued an apology for the errors made and emphasized the organization’s commitment to improving patient care.
In light of the inquest, EPUT has implemented several changes to prevent similar incidents in the future. A clinical psychologist now provides support to young patients transitioning to adult mental health wards, and “nurse transition champions” have been appointed across the trust. Additionally, staff training on patient monitoring has been enhanced, and modifications have been made to the alarm system. These changes ensure that staff will be repeatedly alerted when patients spend an extended period of time in the bathroom, potentially posing a risk to their safety. The aim is to prevent the recurrence of such tragic events and to ensure that all patients receive the high-quality and compassionate care they deserve.