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India Walker: inadequate response by hospital staff to patient who fatally self-harmed

India Walker was just 20-years-old when she died following a serious act of self-harm at Elmleigh Hospital in Hampshire on 16th October 2021. This was her tenth act of deliberate self-harm during her short admission of just over two weeks. 

India was a precious daughter and sister, who was kind, generous, and very musical. As a teenager, she made care packages for homeless people in Reading, and had a large network of pen-pals around the world. Unfortunately, things started to go wrong when she went to university, and she was hospitalised for almost a year before being discharged into the community. Her previous hospital had put in place a comprehensive risk management plan which successfully kept her safe, despite her deliberate self-harm.

India was admitted to Elmleigh hospital on 28th September 2021 due to her mental illness and high risk of self-harm. She had deteriorated whilst in the community and tried to take her own life and deliberately self-harmed multiple times before admission. 

Throughout her short admission, India did not get better. She continued to report suicidal ideation and intent and repeatedly self-harmed. She consistently self-harmed, but her risk management plan was never changed and her crisis plan was never updated. Her observations were never increased and her room was never searched. The jury found that the documentation and recording of incidents of self-harm was inadequate.

The court heard from an independent expert, Dr Chess Denman, a Consultant Psychiatrist and Medical Director.  She initially told the court that the overall care provided to India was ‘adequate’. However, following questions from Matthew around India’s previous admission and risk management plan, she changed her view and agreed that the overall care was ‘less than adequate’.

There were multiple failures on the day of India’s fatal self-harm:

  • India was meant to be on 15-minute observations but the observation due at 23:00 was not carried out until 23:09 (when she was discovered); 
  • The handover of this observation round was unsatisfactory (resulting in the observation being delayed);
  • The speed at which the 999 call was made was inadequate (seven minutes after India was found); and 
  • The CPR administered by staff was inadequate (with over 96% of the chest compressions being too shallow / of insufficient depth). 

The jury concluded that all of these failures possibly contributed to India’s death. The Coroner will hear evidence in relation to Prevention of Future Death matters at a later date. 

The inquest has been reported here:

Matthew Turner represented India’s mother at the inquest, instructed by Claire Macmaster and Bernadette Barrett of Simpson Millar Solicitors.

The Coroner was HM Senior Coroner for Hampshire, Mr Christopher Wilkinson. The other Interested Persons were the paternal family and Southern Health NHS Foundation Trust.  

Matthew is a specialist in both inquests and clinical negligence, with extensive experience of suicides in custody, medical deaths in custody and wrongful death cases. He has secured nine neglect verdicts in different inquests since December 2021.