Failure at Eating Disorder Service A Probable Cause of Melissa Parrish’s Death
A jury in the inquest into the death of Melissa Parrish has concluded that a failure to identify a fault at Vincent Square Eating Disorder Service was a probable cause of the death of Melissa Parrish. The Coroner has asked Central and North West London NHS Foundation Trust to write to him about their safety checks and audits at Vincent Square.
Melissa’s family was represented at the final hearing by Cian Murphy, and previously by Shanthi Sivakumaran, instructed by Basmah Sahib of Bindmans LLP.
Melissa was the eldest of three daughters of Melanie and Michael Parrish. She had been living with an eating disorder since her teenage years. After starting university as a psychology student, she had a relapse of her eating disorder, when a close friend died unexpectedly.
She was twenty four years old when, as a result of her very low potassium levels, she was involuntarily detained pursuant to section 2 of the Mental Health Act 1983. Despite the efforts of her parents to have Melissa engage with out patient services, by 7 June 2018, professionals and family agreed that a period as an in patient was unavoidable.
An earlier period of in patient treatment at another hospital, however, had been traumatic for Melissa, and had led to an overdose. The jury heard how she was “terrified” of being kept in hospital. On 7 June 2018, her parents travelled with her to the Vincent Square, and ambulance staff tried to lift her spirits. Melissa disclosed that she had drunk some alcohol when she found out about her committal.
The jury heard evidence from Melissa’s parents about their concerns at the quality of risk assessment that was undertaken upon her admission. During this time Melissa’s mood became much worse. Her mother found her in obvious distress in the corridor by the exit, hugging herself, saying “I can’t do this” over and over.
After the assessment, and notwithstanding her history and presentation, Melissa was made subject to intermittent observations. Less than half an hour after her parents had left Vincent Square, Melissa was found unresponsive in her room, after a self-inflicted injury, and there was an emergency medical response. She did not regain consciousness.
After three years of hospital and hospice care Melissa sadly passed away as a result of the injuries she sustained that day. The jury concluded that the fault in her room, which had previously been identified in identical equipment on another ward, should have been identified and managed. The failure to do so was, the jury decided, “to a very significant extent a probable cause of death”.
There was little, if any, indication that Melissa intended to end her life. The jury were given the opportunity to consider a conclusion of “suicide” but instead recorded “misadventure”.
In addition to their legal representatives Melissa’s family are supported by INQUEST.
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