Teenager’s death in grounds of hospital in Harlow leads to warning from coroner

Health / Mon 8th Jan 2024 at 08:36am

IN the wake of a teenager’s death, Essex County Council has been warned of a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks reports the Local Democracy Reporter.

Morgan-Rose Hart, 18, died six days after she was found unresponsive in the bathroom of her mental health accommodation in the Derwent Centre in Harlow.

Morgan-Rose had been sectioned under the Mental Health Act before her death, and she was supposed to be in a place where she would be safe and cared for. But a coroner has warned that lessons need to be learnt to prevent future deaths.

Sonia Hayes, coroner for Essex, has told Essex County Council, in her prevention of future deaths report, that there needs to be more provision for people with mental health needs living with autism.

The warning follows an earlier inquest that found the failure of basic protocol and procedure documented by Essex Partnership University NHS Foundation Trust resulted in Morgan-Rose Hart dying by ‘misadventure contributed by neglect’.

She said: “There is a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks in Essex both inpatient and in the community.”

Essex County Council has said it will respond in due course.

Criticism has also been levelled against mental health services in Essex – where there were multiple failings between the time Morgan-Rose was seen at around 2pm and when she was discovered at around 4.15pm.

Staff fabricated records to claim they had observed her properly during this time

Staff had also commented on her appearance despite her living with body dysmorphia and flowers had been incorrectly delivered to her which had also triggered a response.

A technology, known as Oxevision, which uses infrared sensitive cameras in people’s bedrooms to help staff visually confirm a person is safe, measuring vital signs – such as their pulse and breathing rate – without disturbing their sleep was not used properly.

An Oxevision red alert for the bathroom was triggered at 3.31pm but was reset without anyone checking on her. It meant Morgan-Rose was left unattended in her bathroom for approximately 50 minutes after that alert was triggered and the time she was discovered unresponsive on the bathroom floor, in the shower, fully clothes at 4.20pm

An Oxevision alert is triggered if a person is in the bathroom for more than three minutes and staff are required to complete an in-person check

There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 2.06pm could not be correct.

The coroner said: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken.”

A spokesperson for Essex Partnership University NHS Foundation Trust (EPUT) said: “Our condolences remain with Morgan-Rose’s loved ones following their tragic loss.

“We remain absolutely committed to ensuring improvements are embedded throughout the organisation so that all patients receive the high quality and compassionate care they deserve.

“We are thoroughly reviewing the Coroner’s findings and will respond to the report in full in due course.”

A spokesperson for Essex County Council said: “We wish to offer our deepest sympathies to Morgan-Rose’s family and friends on their sad and tragic loss.

“We are aware of the Prevention of Future Deaths report relating to Morgan-Rose and will be responding, as directed by the Coroner, in due course.”

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16 Comments for Teenager’s death in grounds of hospital in Harlow leads to warning from coroner:

Serious concerns about this hospital
2024-01-08 09:09:47

It's not the first time and won't be the last that staff at this hospital have lied to cover their backs and the backs of their colleagues. There are medical staff members there that are a risk to patients and the complaints department and CEO just want complaints dealt with as quickly as possible so there is no bad press and so it isn't leaked to the public. The senior management team needs a big shake up and the CEO needs to go as he also likes to try and brush off serious concerns about staff and the lack of integrity of some that work there. It speaks volumes when the senior management team are allowed to spend over 50k on a trip to Las Vegas!!

2024-01-08 10:53:33

I would never go back to Harlow Hospital, just the name of it makes me infuriated. I was in there for almost 4 weeks with severe COPD. I was containing carbon monoxide & my oxygen levels were very very low .I was so ill, but not once but twice I was left without oxygen...one was they hadn't checked oxygen tank when I awoke in the morning it was empty & I turned blue the second I was sent down to bathroom with portable oxygen that hadn't been turned on, again I came over feeling really weird. It's like being in kiddergarden on the ward, the nurses were larking around like a bunch of children all either giggling with each other, on their phones or just chatting. Or disappeared altogether The hospital could not regulate me or get my oxygen levels up & carbon monoxide down. I felt worse in there than I did at home. Then they told me on last day of coming home I had lumps on my breast & they wanted to put cameras down my throat etc. I couldn't breath at lone have cameras. All of this was very upsetting. I said NO I want to go home I'll take my chances & deal with this. I then after a few days at home went into Papworth & they regulated me sorted out home oxygen & ventilator to help me cope. So Yes Harlow Hospital needs to really shape up & concentrate on & around ALL PATIENTS young or old with every health problem. Some of the staff also need to get their acts together. I will never go back into that hospital if I can help it. I can not have trust in the nursing care. The nursing care is a very big part of the road to recovery & it needs to be taken very seriously.

Crazyhorse 74
2024-01-08 13:20:03

Needs shutting down and new hospital needed asap.

2024-01-08 14:27:27

How many more 'lessons need to be learned'????

Mr Grumpy
2024-01-08 14:50:06

Rather than management wasting money on their "fact finding" jolies, how about the money be better spent on essential front line services. More front line staff means better care for those in need. My own experience of staff at PAH is quite good. After a head injury, they looked after me as well as they could, considering how many were in their charge at the time. As for JR's comments "nurses were larking around like a bunch of children all either giggling with each other, on their phones or just chatting", they need an outlet for the stress they are always under, else they would go mad.

Guy Flegman
2024-01-08 15:54:04

Back in the 1970’s the hospital had small management and seemed to run ok. As time has gone on the number or managers has grown and the service has gone down. It’s not hard to see where the problem is. They need to strip back the management then create continuity across the health trusts. The only problem is you need to get this approved by the existing management, which will never happen without direct government intervention, which again won’t happen as the government look to the existing management for guidance. Personally I think it’s all part of a plan to privatise by the back door. If you have ineffective management and the service declines it makes the case for privatisation look more attractive.

Eric Bookbinder
2024-01-08 16:01:30

I tried to file a complaint at Harlow Hospital once. It took three weeks of emails to get them to even raise it as an official complaint, they wanted to treat it as an unofficial discussion. They said they'd reply in 60 working days. Three months later I asked for an update and they had no idea what I was talking about. I was absolutely furious and demanded an explanation. "An investigation into the reported incident found no evidence of any mistakes or wrongdoing with our staff. Case closed." What?! Coverup. Corrupt, dishonest, cover-your-backside mentality. No care for the patients.

2024-01-08 20:28:25

Mr Grumpy think you should go in & have your head examined again as they obviously didn't get it right the first time. As for JR's comments regarding staff larking around, yes they are allowed to do so BUT ON THEIR OWN TIME & NOT ON THE WARD whilst patients are in their care they are on duty not play ground activities. Think I've said this before Mr Grumpy if you haven't got anything constructive to say then don't say anything at all.

2024-01-08 22:29:56

Ok I’m a little confused are you all talking about the main hospital here or the actual mental health unit the Derwent centre??

2024-01-09 14:59:44

Very sad that a life ended so young. I myself would not blame the front line staff as they are under enormous pressure as it is. If anything I would hold to account the bean counters who always expects more work for less funding. What has our society come to whenoney isore important than lives :(

2024-01-09 15:01:13

whenoney isore?? Should read "whereby money is more"

2024-01-09 15:02:49

Guy Flegman I agree 100%

Edna graham
2024-01-09 20:30:06

HOW about some praise for the staff,they are under so much pressure dealing with so many people from all area's. Bishop stortford/Epping hospitals should have closed. So Harlow has deal with it all.so stop complaining.

Anna Harvey
2024-01-12 08:03:46

Highly likely not enough staff provided to cover the care plan for this poor girl. It's easy to say what should happen but if cuts in staff and working with bare minimum on duty you only need one other incident to take you away from monitoring all the other patients. Very sad for this family and young lady.

2024-01-16 10:27:02

There is absolutely no excuse for Derwent Centre staff falsifying records and lying to the coroners court. By covering up, not following procedure and their lack of care the staff are doing themselves a disservice as the plight of being under-staffed and stressed is not highlighted. This sadly was a young life lost that could have been prevented, sympathies go to the family.

Nobody important
2024-04-23 08:50:20

Derwent Center, I would like to say that I felt like I was in a big "gang" - employees come to sleep at night, and employees are tired during the day? seriously? Working people come here to relax? They don't talk to patients? They take care of each other and play games. You sit there as if you didn't exist! You can find everything in the rooms, because no one cares about anything, this place is not safe, this is a place where the staff provokes with their behavior and then threatens what will they do to you? the staff is aggressive, provoking people to kill themselves. "0" support for several weeks, with limited access to Fresh Air - 5-10 minutes max. Shame! this place needs energy, spirit, and people who feel what they are doing, who love other people's lives as their own! simple rule! take care of me as you would a person close to your heart! not a dog! Being there, I felt that they despised me, I felt like an inferior patient who was only shouted at and shown how you are nothing but a mentally ill, not valuable person. So much experience to find out that I am a nobody! no one important, just an idiot. (the staff still doesn't check, personally, he monitors from the iPad because he's tired)

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