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Young woman took her own life at psychiatric hospital following series of failings by NHS Trust, inquest concludes

Zoe Wilson, 22, was not transferred to an acute ward despite telling staff she was hearing voices that told her to kill herself


Zoe Wilson’s mother spoke to her the night before she died. Her daughter phoned from a psychiatric hospital in Bristol where she was being treated for psychosis.

The 22-year-old asked if she could come home, and said that her imaginary boyfriend, Jacob, was telling her to kill herself.

The following day, when the family were preparing to visit Zoe at Callington Road Hospital in Knowle, they were informed she had passed away.

Zoe had taken her own life. At the time of her death, in the early hours 19 June 2019, she was on twice-hourly observations.

“We will continue to fight for justice in her name. She will never be forgotten”

Zoe’s family

Two years and seven months later, a jury inquest concluded on Thursday that multiple failings by the NHS Trust that runs the hospital may have contributed to her death. Her family is now calling for Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) to face a criminal prosecution for breaches of health and safety legislation.

The findings follow an inquest into the death of 28-year-old Luke Naish, which heard that AWP staff were hugely overstretched, and that a legally-obligated care package was not consistently in place. Alexandra Greenway, a 23-year-old transgender woman from Bristol, also died in 2019 while under the care of the same Trust.

‘Difficulty securing medical support’

In 2018, a year before her death, Zoe was in her final year of a law degree at Exeter University when her mental health deteriorated.

She developed delusional behaviour with episodes of psychosis, and returned home to her family in Bristol. The student’s family said they had great difficulty securing effective medical support for her illness. 

Zoe was admitted under the Mental Health Act (MHA) to Callington Road Hospital in June the same year, before being discharged in September 2018. 

She was then put under the care of Bristol’s Early Intervention Service. But in April 2019, following a further decline in Zoe’s mental health, she was detained on an acute ward in Callington Road Hospital where she remained until 13 days before her death.

Despite her ongoing psychosis, the inquest heard that Zoe’s condition was then reassessed and she was transferred to the low-risk ward Larch Unit of the hospital.

Zoe pictured with her mother, Steph, and father, Rob

‘Inadequate observation’

Zoe pictured with her younger sister, Emilia

Two days before her death, Zoe handed in her belt to staff and told them voices in her head were telling her to kill herself.

Her room was not searched for any other ligatures following that disclosure, nor was that information properly handed over to staff on subsequent shifts, the inquest heard.

In the early hours of 19 June, during twice-hourly observations, Zoe was found standing beside her bathroom door “looking scared” but was not spoken to by staff. More regular observations, or constant, is sometimes used when a patient is deemed to be at a higher risk of self harm.

Thirty minutes after an observation, Zoe was found having ligatured in her room on Larch ward. Emergency services were called but she was pronounced dead.

‘Multiple failings contributed to Zoe’s death’

The jury inquest into her death found that multiple failings by the NHS Trust may have contributed to her death. They included:

  • Inadequate steps taken to keep Zoe safe on Larch unit after she handed in her belt on 17 June and stated that she was hearing voices telling her she should kill herself.
  • Inadequate communication and information-sharing about Zoe between the staff looking after her on 17 to 19 June 2019
  • Inadequate observation of Zoe at around 1am on 19 June 2019, which was the primary mechanism of keeping her safe on Larch Unit

Speaking after the decision, Zoe’s family said Avon and Wiltshire Mental Health Partnership NHS Trust must face a criminal prosecution over its failings.

“There were ligature risks on that ward and that was how she was able to end her life,” her mother, Steph, told Cable. “The ward didn’t meet the standards for safe patient care.”

In statement, the family added: “Zoe was [put] on a low-risk ward by the Trust even when she told staff that voices in her head were telling her to kill herself. 

“Her bedroom was not searched for ligatures even when she told staff she was worried that she was going to hang herself with her belt. 

“She was not spoken to by staff even when was found standing beside a ligature point looking scared in the middle of the night.”

“We will continue to fight for justice in her name. She will never be forgotten.”

Tony Murphy of Bhatt Murphy solicitors, who represent the family, said: “The family now await the CQC’s [Care Quality Commission] investigation into the Trust. 

“Time is of the essence as the three-year anniversary of Zoe’s death approaches in June.”

Avon and Wiltshire Mental Health Partnership NHS Trust was rated by the CQC as ‘requires improvement’ after its latest inspection between July and September last year.

Speaking after the inquest’s conclusion, Dr Sarah Constantine, Medical Director at Avon and Wiltshire Mental Health Partnership NHS Trust, said: “I would like to express my sincere condolences to the Wilson family.  We accept the jury’s findings and recognise that in this instance we did not do everything that we could for Zoe.”

If you’re in crisis and need immediate support, please call 111 or call the Samaritans for free on 116 123.


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