gavelGross failings by Priory Group contributed to the death of 14-year-old Amy El-Keria, who was an inpatient at Ticehurst House private psychiatric hospital, a jury at Horsham Coroner’s Court has concluded.

The jury found that Priory failed to meet Amy's care needs or to properly manage her risk, identifying factors contributing to her death including:

Inadequate staffing levels 

Failures to share key risk and care information with staff

Inadequate systems for identifying and managing ligature risk, placing Amy in an unsuitable room containing high-risk ligature points

Missed opportunities for removing a scarf in Amy's possession (used by Amy as a ligature on the day of her death)

A failure to adequately address bullying of Amy by her peers or to follow Priory's anti-bullying procedures

Failures to pass key information about Amy's increased suicide risk on the day of her death and to increase staff observations in response to that increased risk

A delay in undertaking the final observation 

Failures in the emergency response including delays in calling an ambulance, contacting the duty doctor and commencing CPR 

Lack of training to enable staff to respond to an emergency situation.

Amy had complex health needs associated with multiple mental health diagnoses. Following several incidents involving her use of a ligature and two attempts to strangle herself at home, Amy was urgently referred by West London Mental Health Trust to Ticehurst House in East Sussex – 2 hours’ drive from Amy’s family home – where on August 24, 2012 she was admitted as a patient to a specialist Child and Mental Health High Dependency Unit. This was Amy's first admission to a psychiatric hospital.

At the time of her admission, Amy was deemed at high risk of self-harm and suicide. Her conditions were said to cause her difficulties with forming friendships with peers and she was known to be at risk of isolation. Central to her care plan was daily provision for one-to-one personal time with staff, including to have bedtime stories read to her at night. 

Although a patient at Ticehurst House for less than 3 months, inquest evidence detailed 6 incidents of restraint – several involving forced sedative injections applied against Amy's will. The first restraint occurred within 2 days of Amy's arrival, involved 4 members of staff and lasted 15 minutes. The last incident occurred the day before her death, when Amy was restrained by 5 members of staff for 15 minutes and orally sedated.

The jury heard evidence of Priory's failure to notify Amy's mother of many of these incidents of restraint and forcible sedation, as well as incidents of self-harm and suicide threats made to staff.

On November 12, just after midnight, Amy told staff she had tried to hang herself saying she wanted a one-to-one but no-one had time. On the afternoon of November 12, Amy had also told medical staff she wanted to hang herself. This information failed to prompt a risk review, no search of Amy's room was carried out to check for and remove potential ligatures and there was no increase to the frequency of staff observations levels from the standard 15 minutes set for the duration of Amy's admission.

At approximately 20.17 a healthcare assistant found Amy’s bedroom locked – she was due to be checked at 20.12. She returned with keys to access Amy’s room and found her collapsed on the floor. CPR was not immediately commenced until arrival of the duty doctor. An ambulance was not called until 20.27. Amy was transferred by ambulance to hospital but never regained consciousness. No staff travelled in the ambulance with Amy and it was not until Priory staff telephoned at 22.55 on November 12 that her family were informed.

Healthcare witnesses spoke of over-stretched staff working in over-pressured conditions, with insufficient time to meet the needs of the children on the unit. For instance, they rarely had breaks from continuous 1:1 observations – not even toilet breaks – high reliance on agency staff including those with no psychiatric experience, insufficient time to read patients key paperwork or clinical notes, poor communication and strained relationships between staff and management and lack of basic training.  

One healthcare assistant described her repeated requests for first aid training being ignored and feeling ill equipped to fulfil her role without this, with restraint training given only 8 or 9 months into post. Another nurse resigned shortly after Amy's death, stating that he believed the organisation was responsible for Amy's death and that he felt Amy's suicide was avoidable had the unit been better resourced. 

Amy’s family, the Priory, 2 individual doctors, West London Mental Health NHS Trust and London Borough of Hounslow Social Services were all represented as Interested Parties.

Tania El-Keria, Amy's mother said: "Amy was my most loved youngest daughter, sister, niece and granddaughter with her whole life ahead of her. She had a warm heart and a great sense of humour. She never liked to see people treated unfairly and would be the first to stand and say "that's not right".

“For14 years we kept Amy safe. In less than three months under the care of the Priory she was dead. The only thing that has kept me going since her death nearly four years ago has been the need to achieve justice for my Amy.    

“I knew the Priory's investigation following death was a whitewash and this inquest has proven that.  If I had treated Amy and neglected her needs in the way Ticehurst house did she would have been taken away from me. 

“I don't blame junior staff for what happened to Amy, I blame the Priory for failing to put in place the systems needed to keep her safe and for ensuring she received the care and treatment she so desperately needed.

“Had she lived, Amy would have turned 18 during this inquest hearing. I am so sad that others will not have the privilege of meeting someone as caring, loving and exceptional as Amy. The most important thing to me now is to change the system which is failing to provide the mental health care our children need. I will continue this fight in my Amy's name." 

Deborah Coles, director of INQUEST, which has supported Amy’s family since her death, said: “The jury findings are an indictment of a mental health system that placed a child far away from home, in a private unit operating dangerous and grossly inadequate systems of care The desperate catalogue of failings exposed at this inquest all point to a system that is shamefully failing our responsibilities of care for vulnerable children. 

“This evidence has only been exposed now, four years after Amy’s death, as a result of the family’s fight for a full inquest with a jury, resisted by the Priory. 

“We must question the marketization of children's mental health, with the lack of visibility and structures of accountability that this brings.

“The only possible response to this case and the growing public outcry around mental health services for children and young people is for an urgent independent review. We call upon the Government to now take this necessary step. A failure to do so will almost certainly result in the further unnecessary deaths and suffering of more children.”

Tony Murphy, the family's solicitor from Bhatt Murphy: "The jury's powerful conclusions follow a four-year battle by Amy's family to establish the truth. The disturbing circumstances of Amy's death reveal the dangers involved in the NHS outsourcing psychiatric care of vulnerable young people to remote private institutions."