Inquest finds health worker's failure led to death

A 19-year-old woman detained under the Mental Health Act died as a result of "gross negligence manslaughter by an agency healthcare assistant", an inquest has found.

Louise Furlong died on 12 September 2022 at the Queen's Medical Centre (QMC) in Nottingham, the day after being found in a bathroom at Highbury Hospital.

A jury inquest at Nottingham Coroner's Court had earlier heard Sylvia Quaye-Mensah had failed to carry out scheduled checks on her, then falsified records to cover her actions.

The jury returned its conclusion on Friday.

The inquest heard Furlong - referred to in court as Lou-Lou - had a history of self-harm and received a diagnosis of "emotionally unstable personality disorder".

Furlong was in specialist residential care after turning 18, and on 5 June 2022 she was taken to Bassetlaw Hospital, where she was kept until her transfer to Highbury Hospital on 7 September, which occurred after police raised safeguarding concerns.

The inquest had heard neither Furlong nor a multi-disciplinary team meeting at Bassetlaw Hospital on 6 September had been made aware of the transfer plans.

In its conclusions, the jury said it could see "no clinical rationale" for the transfer, and said there was "no plan" from the hospital for her care after the transfer and no formal handover.

The jury said the nature of the transfer "probably more than minimally contributed to her death".

Once at Highbury Hospital, in Nottingham, the jury said staff "managed Lou-Lou's risks effectively" and that 10-minute observations were the "appropriate level" for her.

"She appeared more settled after having slept and eaten some toast, so we believe her risks were managed effectively and interventions in place were sufficient prior to 18:00," they said.

After 18:00, Quaye-Mensah was due to carry out the 10-minute welfare checks for the next hourly period, but the jury found she failed to complete a number of these checks, some of which were falsified.

When giving evidence, Quaye-Mensah - who the jury later learned had pleaded guilty in Nottingham Crown Court to neglect by a care worker in November - declined to answer numerous questions while giving evidence, which is allowed under rule 22 of the Coroners (Inquest) Rules 2013, protecting witnesses from incriminating themselves.

Furlong was last seen alive at 18:34 and then found on the floor of a bathroom with a ligature around her neck at 19:09 by another care worker.

CPR was carried out shortly afterwards and an ambulance was called, which took her to the QMC where she died at 12:30 on 12 September.

The jury said the failure to carry out observations "probably more than minimally contributed to Lou-Lou's death".

A medical cause of death was recorded as "hypoxic/ischaemic brain injury" and "application of [a] ligature around the neck".

After the jury returned its conclusions, assistant coroner Alexandra Pountney confirmed she would not be issuing a prevention of future deaths report as she was "satisfied" with changes made by Nottinghamshire Healthcare NHS Foundation Trust - which runs Highbury Hospital - since the death.

Speaking after the inquest, Carmel Bushell said her daughter "trusted the people around her to keep her safe", but "was failed when she needed protection the most".

"The inquest and earlier criminal proceedings have been an extremely difficult process for our family but they were important to us," she said.

"Nothing can ever bring my daughter back, but I hope that by telling Lou-Lou's story, lessons will be learned and other families will be spared this pain."

Diane Hull, chief nurse at the NHS trust, said: "On behalf of the trust, I once again offer our deepest condolences to Louise's family and friends.

"We fully accept the findings of the jury and the coroner and apologise unreservedly for aspects of care which were not of the standard Louise deserved.

"We must make sure we provide safe and compassionate care for everyone who uses our services every time they need us.

"We're working hard to make this happen and we're sorry that we did not meet Louise's needs in this way.

"We have got better at listening to families and involving them in decisions about their loved one's care and this will continue to be a priority area for improvement."

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