19 Dec 23

Morgan-Rose Hart: Neglect contributed to death of teenager with autism

Morgan-Rose Hart died on 12 July 2022, shortly after her 18^th birthday, after ligaturing whilst an inpatient at the Derwent Centre, an Essex mental health hospital. An inquest jury has found that neglect contributed to her death.

Tom Stoate of Doughty Street Chambers Inquests and Inquiries Team represented Morgan-Rose’s mother, instructed by Rachel Harger and Khariya Ali of Bindmans LLP and supported by INQUEST.

Morgan-Rose was an aspiring vet with a passion for animals and wildlife. Kind and funny, her family said that Morgan-Rose would put others before herself and helped many other young people during her own difficult times.

Morgan-Rose was diagnosed with autism and ADHD, and her mental health had been badly affected by bullying, causing her to move school several times. In 2019, Morgan-Rose’s mental health began to deteriorate, and her Body Dysmorphic Disorder (BDD) became unmanageable. From 2020 onwards, Morgan-Rose experienced multiple admissions to hospital under section.

Shortly after her 18^th birthday, and only three weeks prior to her death, Morgan-Rose was transferred to Chelmer Ward at the Derwent Centre in Harlow, an adult acute mental health unit run by the Essex Partnership University NHS Foundation Trust (EPUT). She spent the vast majority of her three weeks there in her room, and in that time her observation levels were reduced from constant to hourly.

On the afternoon of 6 July 2022, an automated Oxevision alert – a vision-based patient monitoring system that uses infrared-sensitive cameras –notified staff that Morgan-Rose was going to take a shower, a noted blind spot and recognised risk area in patients’ rooms.

Contrary to Trust policy, this alert was reset without any physical check of Morgan-Rose's safety, and Morgan-Rose was not found, unresponsive in her bathroom on Chelmer Ward, more than 50 minutes after the alert was disabled, having ligatured.

The inquest jury concluded that Morgan-Rose died as a result of neglect (gross failures to provide basic medical care). In their narrative conclusions the jury found that:

Morgan-Rose’s transfer from child to adult services was not sufficiently supported; and on transfer, information about her medical history, diagnoses, and triggers were not filtered down to the staff who were providing her day to day care;
Nobody removed risk items from Morgan-Rose at any time during her three weeks on Chelmer Ward, despite the fact that she arrived on constant observations due to her high risk of self-harm, including a history of ligaturing;
There was no subsequent risk assessment of Morgan-Rose’s property when her observation levels were downgraded;
There were no records of meaningful therapeutic engagement with Morgan-Rose, despite the observation records being signed off by nursing staff;
There were no risk assessments made concerning Morgan-Rose’s triggers for self-harm;
Food and fluid charts were inadequately completed, despite concerns that Morgan-Rose was losing weight;
There was no escalation of, and no change was made to, Morgan-Rose’s observation levels when she attempted to access unescorted leave without the permission of her Responsible Clinician on the morning of 6 July 2022;
Observations were falsified by staff in the observation records, meaning that although she was on hourly observations, Morgan-Rose’s last physical observation took place at around 14:06 hours on 6 July 2022;
Patients’ observations were mainly being completed via the Oxevision system, in breach of EPUT policy and despite the fact that most ward staff were not trained to use Oxevision;
No staff member attempted to make a physical welfare check on Morgan-Rose until she was discovered in the bathroom at 16:20 hours.