Medical Negligence Lawyers Support Loved Ones After Hospital Trust Apologises That 32-Year-Old “Did Not Receive The Care She Should Have”

The family of a mum-of-one who took her life after going missing from a mental health hospital are calling for lessons to be learned after an inquest found “neglect” contributed to her death.

Rachel Jones became an inpatient at the Langley Green Hospital’s Coral Ward in Crawley in April 2022.  The 32-year-old was detained under the Mental Health Act.

On 5 May, hospital staff lifted restrictions and a plan was put in place for Rachel’s discharge.  However, during an assessment that afternoon, Rachel said she intended to take her own life after she was discharged.  

Risk assessment not updated

Rachel’s risk assessment was not updated and she was granted leave for 15 minutes. She failed to return at the agreed time and turned up at her mum Lorna’s house.  Lorna expressed concerns over the plan to discharge Rachel, who was taken back to hospital that evening.  

At 10:40am on 6 May, Rachel, of Crawley, asked to be let off the ward for 15 minutes. As she had already been out that morning and had returned safely, the leave was granted. She returned very briefly on two occasions and left for the final time just before midday.

At 2.15pm, police turned up at the hospital to inform staff that a woman’s body had been found near Ifield train station.  The body was identified as Rachel.  She had been fatally injured by a train. 

Sussex family asks medical negligence lawyers to establish answers following Crawley mum's death

Following Rachel’s death in May 2022, her family instructed expert medical negligence lawyers at Irwin Mitchell to help secure answers and support them through an inquest.

At an inquest at Edes House in Chichester, senior coroner Penelope Schofield recorded a narrative conclusion that Rachel took her own life, however her death was “contributed to by neglect.”  

Inquest finds 'failures' and 'missed opportunities' in Rachel's care

She stated there had been “failures” by the hospital to notify the nurse in charge when Rachel returned to the ward on 6 May asking for money, whereby she should have been reassessed by the nurse in respect of a further period of requested leave. 

There was also a failure to check on Rachel’s whereabouts and follow the AWOL policy when she hadn’t returned after 15 minutes.  Ms Schofield recorded that it was “probable” these “contributed to” Rachel’s death.

She added there were also “missed opportunities” by the hospital that “may have contributed to” Rachel’s death.  These were to “respond appropriately” to the report on 5 May that Rachel intended to take her own life on discharge and also to update the risk assessment with concerns following the events of 5 May.

Sussex NHS Trust apologises to Rachel's family

The Sussex Partnership NHS Foundation Trust, which runs Langley Green Hospital, carried out a Serious Incident Review and has now written to Rachel’s family offering its “deepest apologies that Rachel did not receive the care she should have.”  It also confirmed that changes are being implemented following Rachel’s death.

Catherine Knight is the specialist medical negligence lawyer at Irwin Mitchell representing Rachel’s loved ones including her mum Lorna Wilson.

Expert Opinion

“The past year has been incredibly difficult for Rachel’s family who are still struggling to come to terms with losing her so suddenly and in such tragic circumstances.

“They also had several unanswered questions over what happened that day and leading up to Rachel’s untimely death.

“We know nothing will ever make up for their loss, and the inquest has undoubtedly been tough for them, but at least they have been provided with the answers they deserve.

“Sadly, the hearing has highlighted worrying issues in the care Rachel received prior to her death. It’s now vital that lessons are learned to improve patient safety. We therefore welcome the Trust’s pledge to make changes.

“People with mental health problems are some of the most vulnerable in society and it’s vital that they receive the best level of care at all times.

“We’ll continue to support Rachel’s loved ones at this distressing time.” Catherine Knight

Mental health: Rachel Jones' story

Rachel was admitted to the Coral Ward at Langley Green Hospital on 29 April, 2022.

The inquest in June heard that around 10.40am on 6 May, 2022, Rachel – who had been downgraded to an informal patient the day before – left the hospital to go for a cigarette. 

The court was told that she returned to the ward and asked for money. However, the request was not escalated to the nurse in charge.  The Hospital Trust admitted that had the nurse in charge been aware, she would likely have performed a risk assessment and, given the concerns raised regarding Rachel’s intentions to take her own life, would not have let her off the ward again and, if necessary, detained her under the Mental Health Act.

Rachel left the ward at 10.48am and travelled to a friend’s house. The inquest heard that Rachel’s friend was concerned for her welfare and returned her to the ward at 11.50am.

During the time Rachel had bene off the ward, staff had not triggered the AWOL policy and despite doing hourly observations, were not cross checking with the leave record which would have flagged that Rachel was missing, the hearing heard. 

Following her return at 11:50am, Rachel spoke to the receptionist, who had not been aware that Rachel should have been reported as missing, and then left again a couple of minutes later.

Around 2.15pm, police officers attended the hospital and informed reception staff that a body had been found.  It was at that time that staff first realised Rachel was missing, the inquest heard.

Hospital Trust introduces changes

Since Rachel’s death, the Hospital Trust has admitted the “standard of care provided to Rachel was not as it should have been.”  

As a result, the inquest was told that the following changes have been implemented:  

• The nurse in charge is to hold all information about patients, with the nurse in charge or a registered mental health nurse on shift being the only staff members able to grant leave;
• Only staff who have been through the Trust’s full induction process can prepare risk assessments;
• The leave log form has been updated to provide a fuller picture and ensure this captures the time a patient is due to return;
• Staff have been trained to cross-check the leave sheet with the observations sheet to ensure that a patient who hasn’t returned at the expected time is flagged as missing as soon as possible, and in line with AWOL policy;
• Updating of the entire AWOL policy in conjunction with Sussex Police as a result of lessons learnt from Rachel’s death.

Family reveal heartbreak over Rachel's death as they campaign for improved mental health care

Rachel was a former carer who left her job when she became mum to Tommy, four.  Following her death, Tommy is being cared for by his dad, who was also Rachels’s partner, Tom De Feria, 32, and Lorna, Rachel’s mum.

Lorna said: “Since losing Rachel, there’s a huge hole in our lives.  She was the best daughter, sister, partner and mum, and it’s heartbreaking that she’s no longer with us.

“Her mental health had been a struggle for a few years, but we were hopeful that she was getting the help and care she needed to be able to return home.

“The day Rachel died will be etched into my memory forever, and the pain is still as raw as it was back then.  Not a day goes by when we don’t wish she was still here, and to know that she didn’t get the care she should have is really tough to accept.

“We would do anything to have Rachel back, but we know that’s not possible, and the inquest has been upsetting for us all.  The only comfort we can take from it is that we have some answers.

“All we can hope for is that mental health services improve to prevent other families from suffering like we have.

“Our priority now is to raise Tommy how Rachel would have wanted and make sure that he knows every day how much she loved him.”

Find out more about our expertise in helping establish answers for families concerned about a loves one's care at our dedicated medical negligence section. Alternatively to speak to an expert contact us or call 0370 1500 100.