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Widespread failings in hospital death case, says inquest

AN INQUEST into the death of a woman in a private hospital has found that there were widespread failings in her care and neglect contributed to her death.

Lily Lucas, 28, died after being found unresponsive while she was an NHS inpatient at privately run Cygnet Hospital in September 2022.

She had been admitted in Kewstoke, Weston-super-Mare, three months earlier under Section 3 of the Mental Health Act.

Ms Lucas has a history of mental ill-health and a diagnosis of schizophrenia and had hopes that the hospital admission would be an opportunity to get better through engaging with therapeutic opportunities at the unit.

Days before her death, she was prescribed clozapine to help manage her symptoms, despite concerns raised by both Ms Lucas and her family on the side effects of the drug. 

In the hours leading up to her collapse, Ms Lucas was noted by numerous staff members to be drinking excessive volumes of fluids, eating large quantities of food, vomiting and acting in a disinhibited and disorientated way.

The inquest into her death found that she died from cardiac arrest due to complications of psychogenic polydipsia, resulting from her schizophrenia.

There was a failure to adequately monitor Ms Lucas’s worsening mental and physical condition, a jury found, and there was inadequate response and concern for her ongoing state.

Opportunities were missed to render care that would have prevented death, it concluded.

In her evidence, the nurse in charge explained she was unable to fulfil her role properly due to unsafe staffing levels, meaning that opportunities to save Ms Lucas’s life were missed.

In a statement, Ms Lucas’s family said they were grateful for the jury’s careful consideration and that the conclusion confirmed their worst fears. 

“It is… utterly heartbreaking to know that her death was entirely avoidable,” they said.

Selen Cavcav, senior caseworker at the campaign group Inquest which supported the family, said: “Grossly inadequate failures in this case to provide the most basic mental health care is sadly not unique but part of a systemic pattern of failures.

“This is another shocking example of unaccountable private companies like Cygnet putting profit before patient safety.

“We can no longer tolerate the use of public money to fund private provisions which are failing to keep people safe.”

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