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Investigation and inquest
On the 15th September 2020, I commenced an investigation into the death of Rebecca Begg, aged twenty one years. The investigation concluded at the end of the inquest on the 17th November 2021.
The conclusion of the inquest was a Narrative Conclusion as follows:
Rebecca Begg, 'Becca', died at Heathcotes, Moorgreen in the early hours of 15.9.20, from the ████████. She had ████████ some 10 to 15 minutes prior, and this had been removed by staff.
Becca had a diagnosis of Emotionally Unstable Personality Disorder, and had known high risk self harm and suicidal behaviours. Becca put a ████████ as she was very distressed. This was a usual and repeated behaviour that Becca knew from previous experience, led to a reduction in her distress.
Had the team at Heathcotes who were responsible for providing care for Becca properly assessed and understood her high level of risk, her care plans would have reflected both her risk and support needs, specifically that she had previously ████████ repeatedly over a short time period leading to unconsciousness.
Had there been a Team Leader on duty overnight, present with the three other members of staff, on a balance of probability, this would have led to the allocation of a member of staff to remain with Becca following the first ████████
If Becca has been in line of sight observation following the first ████████ as per her care plan, on a balance of probability, she would not have died.
Becca’s death was contributed to by Neglect.
Circumstances of the death
In brief, Becca died at Heathcotes, Moorgreen, a community specialist unit for adults with Emotionally Unstable Personality Disorder, or EUPD. She had moved there following her discharge from The Priory hospital on 31.8.20, some two weeks prior to her death.
At the point of discharge from The Priory, and at Moorgreen, she was a voluntary patient, but had been detained initially on admission to The Priory in June, on a Section 2 and then 3 of the Mental Health Act 1983. She had been detained six times previously, including for prolonged periods, because of the assessed high self harm risk.
Becca had a long history of serious self harm, including ████████. On the night of her death she had ████████ at approximately 22.45 hours. This was ████████ by staff, and she seemed to settle with talking support and Diazepam.
She was left in bed, and then found a few minutes later in her bathroom, blue and unresponsive, with a ████████. Despite ████████ and her receiving resuscitation by staff and the Ambulance service, she did not respond and was pronounced deceased at 00.13 hours on 15.9.20.
Coroner’s concerns
Failure to monitor compliance with care plans, and a lack of robust incident reviews – whilst welcome changes are planned with improved audit and monitoring, this is not yet fully implemented
As yet untested ‘observation level’ support plans
A lack of inclusion of support workers in regular meetings about clients- it is these staff working each day with clients, that can contribute to progress review, and if necessary to a change in the support plans and/or risk assessments
No dedicated time for staff to read and digest care plans
Lack of clarity regarding who can instruct for a room to be stripped following an incident of serious self harm
Lack of a system for formalised contact with Nottinghamshire Healthcare NHS Foundation Trust (NHCT), including if Heathcotes are unhappy about the response from the Mental Health teams, a means of escalation to NHCT senior team
Information checked against the published report and official responses