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Campaigners welcome inquest into death of teenager

Family questions care and support of child and adolescent mental health services and private hospital

Mark Gould

Wednesday, 01 April 2015

Campaigners have welcomed the start of the inquest into the death of a 17-year-old with a history of self harm and mental health problems who died in a private mental health unit.

Sara Green was found dead in March last year in a private room at the Orchard Unit, Cheadle Royal Hospital in Stockport, a specialist unit for young people with mental health problems ran by the Priory Group. She had ligated herself with the wire used to bind spiral note pads.

Her family hope that the inquest will scrutinise quality of support and level of management she received from both Child and Adolescent Mental Health Services (CAMHS) and the Orchard unit. Deborah Coles, co-director of Inquest, the charity which campaigns for justice for people who suffered bereavement as a result of a death in custody, said:

“This death of a young girl in a private institution, placed there because of her established vulnerabilities, must be the subject of the most robust scrutiny.”

Ms Green was the victim of bullying in her teenage years and suffered from mental health problems which included a prolonged period of self harming. She developed Obsessive Compulsive Disorder and was initially referred to Grimsby CAMHS. Between 2011 and 2013 she suffered bouts of ill health and medication overdoses. She was taken to an adult ward in Doncaster where she ligated with a bed sheet. She was then transferred to an adult ward in Scunthorpe before being transferred to the Orchard Unit, in July 2013.

A number of self harming incidents followed including one involving a ligature where staff had to cut her hair without the consent of Sara or her family. Sara’s mother was informed that there was no other alternative to release the tension and that Sara had tried to ligate several times that night. Sara was given injections to apparently calm her down and minimise any disruption without consent from her mother.

On 18 March 2014 a friend of Sara’s on the ward found her on the floor of her room. Staff entered Sara’s room to discover she had ligated with a wire used to bind note pads. Despite efforts from staff and emergency response personnel, Sara was pronounced dead on 18 March 2014.

The family want the inquest to address the way Sara was managed in July 2013 on adult wards and wish to have clarity as to why a decision was made to reduce Sara’s observations from once every five minutes to once every fifteen minutes by her consultant psychiatrist on 18 March 2014, without notifying her mother. Amongst other issues the family also wish to clarify the discrepancies in timings of when observations were carried out that evening and the use of agency staff at the Orchard unit.

The inquest opens on Tuesday next week at South Manchester Coroners Court.

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