“Mental Health Trust Staff on Longfield Ward: a”

The coroner’s concerns

– 1. Mental Health Trust Staff on Longfield Ward: a. Elise was neurodiverse and staff were not trained in Autism b. were inexperienced. The majority were new bank and agency staff with limited experience working with detained children, and this matter had been raised by the Care Quality Commission about other Trust services in January 2021. c. Did not have sufficient staffing to conduct observations required by the doctors for patients on the ward. This was known to the mental health Trust management and had been raised by the ward manager. During the time of Elise’s admission, the staff member allocated for observations for patients was required to conduct approximately 66 observations within an hour. This was not logistically possible. Management knew that staffing allocation on Longview Ward was not sufficient to conduct the required levels of observations to keep the patients safe. Evidence was heard during the inquest that there are still observations that are not being conducted either as required or at all within the Trust and remains an ongoing concern. Datix reporting incidents are not always raised. d. The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system. There were difficulties with the roll out on St.Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision system not operating correctly. e. The clinical management at the Trust Project Board meeting overseeing the roll out for Oxevision, required that ward staff implement a procedure where the Oxevision fixed monitor in the ward office be observed 2 by a member of staff whilst the WiFi problem was resolved. This did not happen on Longview Ward. f. The Trust Project Group had reports that WiFi was not working and any issues were required to be reported as incident reports on Datix forms but these were not being completed. The Trust Project Board did not question why they were not receiving the Datix forms with the known issues. There was no oversight of what was required to ensure that the roll-out was operating appropriately and/or what the Project Board expected in the interim whilst the WiFi difficulties were being investigated. g. Not all the Trust staff on the ward were trained to use the Oxevision System. h. There was disputed evidence about the volume on the fixed terminal for Oxevision in the office about whether the alert volume could be turned down or ‘muted’. It was established that there was an incident unrelated to Elise’s death where a doctor did turn this volume down on the ward. 2. Elise’s medication changes whilst in mental health hospital were not correctly entered onto the medication chart: a. Elise asked for changes to her medication and then reported that these changes were not therapeutic. It was agreed with her consultant that her previous regime would be implemented. The medication was crossed out and removed from the prescription chart. Sertraline 200mg was re-prescribed by the consultant but not entered onto the medication chart and not administered. b. Nursing staff did not query the sudden cessation of medication for treating mental health with no replacement or explanation given. Elise suffered a significant deterioration in her mental health during this time, the frequency and severity of ligatures increased, and Elise had to be placed under section 3 Mental Health Act. c. There was no pharmacist scrutiny just prior to the Bank Holiday and the medication error was only noted 3 when questioned by Elise’s family when she went on home leave. 3. There was poor communication between ward staff and vital information about self-harm and ligaturing was not handed over on shift change. It was undisputed that Elise tied 12 Ligatures between 7th and 14th April and on 15 April. The Datix incident recording gave minimal details and only the ligatures from the 13th and 14th were recorded on the whiteboard in the nurse’s office. 4. Mental Health Trust staff falsified Elise’s observation records and this was not identified by the Trust post-death investigation despite the availability of timings from Oxevision imaging. This matter arose in an inquest that significantly post-dated Elise’s death and there is concern that lessons had not been learned. The Trust internal investigation does not refer to this and these matters are arising with scrutiny within the inquest hearing. 5. The observation level for each young person is decided by the medical staff at the Trust and can be altered dependant on the patient’s risk level. The Trust Policy had a protocol on how observations should be conducted. All observations should be recorded by the staff on formal observation sheets. There were sheets for Level 1 and another sheet for the levels 2,3 & 4. Risk assessments were incomplete and not all ligatures were included The entries in the records were not all consistent, some contradicted others and this included the levels of observations required to keep Elise safe on the observation charts that were required to be completed. This was confusing and remains a concern as these are entries made by qualified Trust staff who have received training in observations. During the Trust internal investigation after Elise’s death, the investigator visited the ward and found observations were not being conducted in accordance with the Trust Policy. 6. Detained patients including Elise were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision. On 17 April the activity coordinator left a box of mobile phone chargers and headphones that posed a ligature risk, with a member of ward staff in a communal area, asking that she look after this whilst he collected some takeaway food that had been ordered by patients from the ward entrance. On his return, the box was unattended in the presence of patients with a high risk o

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0078

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0