1 day Ago By Tara Cobham
A mother whose daughter was found to have been neglected by a hospital before taking her own life has blamed the “failures of the system” for her daughter’s death and has demanded improved care for future patients . Court documents show Iona Imogen Lee’s suicide is one of at least five deaths that failures at Derbyshire ’s mental health units caused or contributed to in the past decade. The health and social care regulator is currently reviewing information over three deaths at the units.
Morag Lee, 57, opened up about her “inspiring, friendly, loved” daughter Iona’s heartbreaking final hours on the Hartington Unit at the Chesterfield Royal Hospital in Chesterfield, before the 24-year-old was transferred to the ICU where she died on 18 September 2023. The 57-year-old, from Derby , spoke to The Independent after a coroner ruled in January that her child had died by “suicide contributed to by neglect” on the ward where she had been detained under the Mental Health Act on 15 September 2023. Ms Lee said: “The inquest into Iona's death was a devastating experience, revealing tragic failures of the system that directly contributed to her passing.
“I’m still trying to get my head round that, that’s what still wakes me up all hours of the night – realising how much chaos was around her and how little support she got and how disregarded she was in her last few hours, that destroyed me. She had to go through that on her own at the place where she should’ve been safest.” The Care Quality Commission (CQC) has carried out several inspections since 2023 due to concerns raised and incidents, including death, at the Hartington Unit and the Radbourne Unit, at the Royal Derby Hospital in Derby.
The wards were the two inpatient mental health units for working age adults under the Derbyshire Healthcare NHS Foundation Trust until the Hartington Unit’s services transferred to the new Derwent Unit last month. The regulator said its latest inspection showed that the provider had worked hard to reduce risks so the conditions placed on the Trust were removed, with the services’ rating raised to “good” – but the CQC confirmed it is currently reviewing information over three deaths at the units. The Trust apologised for its failings in Iona’s care, with “significant improvements” taking place across its acute inpatient facilities in recent years.
It was found at the inquest into Iona’s death in January that “there were a series of errors in the planning, management and implementation of Iona's observations after admission” and that “instruction, information and supervision were all inadequate, as was the primary induction”. The jury concluded that Iona’s observation level should have been raised to being kept within staff’s eyesight, but due to staff shortages on the ward, she was only being checked intermittently. Even then, this should have been at least every 15 minutes, but the 24-year-old was not found until 43 minutes after she was last seen.
Ms Lee said: “It's heartbreaking to know she was left unchecked for so long, and the thought of her final 43 minutes, alone, is unbearable.” She raised “serious concerns” about the management of the Hartington Unit and believes blame also lies with this and previous governments in their role overseeing a crippled NHS. Inquests over the last 10 years identified failures by the Hartington and Radbourne Units that caused or contributed to at least five deaths, including over incorrect decisions around patients being granted leave or discharged from the wards, wrongful prescription of medications, and inadequate risk assessment.
A coroner issuing a warning to the Trust for policy change for fear of risking future deaths. Calling for change for future patients, Ms Lee said: “In the past year, the hospital have changed their policies, but guidance was in place two years ago that wasn’t followed and led to my daughter’s death – so how do we know that what’s in place now will continue being implemented? What reassurances does the public have?” In January, the Health Services Safety Investigations Body (HSSIB) raised concerns that the healthcare system “is not learning” from safety investigations that occur after a person died during or shortly after care during a stay in a mental health facility. Mark Powell, Chief Executive for Derbyshire Healthcare NHS Foundation Trust, said: “I apologise to Iona’s family and deeply regret the pain and distress they have experienced.
“Our services aim to uphold the highest standards of patient safety, offering trauma informed therapeutic care. We thoroughly investigate all incidents and are committed to learning from internal and external reviews, recommendations from HM coroner and feedback from families and carers to ensure we learn and make ongoing improvements to our services.” He continued: “I offer my deepest condolences to those who have sadly lost a member of their family while they were in our care.
I am very sorry for any learning that suggests there were failings in the services previously provided.” He added that two new units are opening this spring, offering improved privacy, dignity and safety features. A Department of Health and Social Care spokesperson said: “This government inherited a broken NHS and it is unacceptable that mental health patients have not been getting the care and treatment they deserve.
“We are reforming the Mental Health Act so patients are treated with dignity and respect, recruiting 8,500 more mental health workers, and publishing a refreshed workforce plan to ensure the NHS has the right people, including in mental health settings, to deliver the care patients need.” If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email [email protected], or visit the Samaritans website to find details of your nearest branch.
If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week.
If you are in another country, you can go to www.befrienders.org to find a helpline near you.
