Home / Insights / Inquest finds neglect contributed to death

Inquest finds neglect contributed to death

A three-week inquest into the death of Bethany Lilley, 28, has concluded that her death was contributed to by neglect due to a plethora of failings by Essex University Partnership Trust.

HM Area Coroner Sean Horstead and the jury heard a range of evidence regarding Bethany’s death whilst an informal patient on Thorpe Ward at Basildon Mental Health Unit. Her death is one of a series of contentious deaths of patients in the care of Essex mental health services, prompting extensive campaigning of bereaved families and an independent inquiry.

Fosters’ Jenny Fraser and Jonathan Metzer of 1 Crown Office Row Chambers represented Bethany’s family at the inquest at Essex Council Chambers in Chelmsford.

Responding to the conclusions, Bethany’s family said: “We are grateful that we now have the answers we have been longingly seeking for after three long years.  We feel vindicated by these answers and that Bethany’s death was taken seriously by the jury.  We are finally able to remember Beth for the lovely, funny beautiful daughter, sister and aunty she was instead of focusing only on how she died.  We thank Jonathan and Jenny for their fantastic support in reaching this stage.  We now have justice for Beth!”

Jenny Fraser of Fosters Solicitors, added: “This conclusion truly reflects the evidence heard over the past three weeks.  It has highlighted critical failings that need to be addressed to ensure that other deaths do not occur.  I hope that Essex Partnership University Trust do take these failings on board and learn lessons.  It is not acceptable that such basic measures which could have prevented Bethany’s life being endangered were not undertaken.”

Background to case

Bethany was an ambitious young woman who had previously worked as a Health Care Assistant in a GP Surgery. She felt she had found her vocation in helping people and wanted to work in mental health care. She experienced complex mental-health difficulties and had a diagnosis of Emotionally Unstable Personality Disorder (EUPD) which ultimately impacted her ability to work.

Prior to her death, Bethany had a history of psychiatric inpatient admissions, including a seven-month admission under Sections 2 and 3 of the Mental Health Act 1983 between January and July 2018. Bethany’s condition significantly improved following this admission.

However, Bethany suffered a deterioration in her mental health a few months later following the unexpected death of her father in late October 2018. This led to a rapid escalation of self-harming and suicidal behaviours. She was admitted as an inpatient on several occasions, including in November and at the end of December 2018. She was then discharged from hospital on the 3rd January 2019, despite three ‘near miss’ incidents which almost led to her taking her own life on 1st, 2nd and 3rd January. The jury found this to be inappropriate and possibly contributory to her death.

Bethany’s final psychiatric inpatient admission was on the 9th January 2019, just six days after her previous discharge. It followed further significant self-harming. She was admitted as a voluntary patient at Peter Bruff Ward, Colchester. From the evening of her admission, Bethany continued to display high risk and suicidal behaviour which included multiple ligature and self-harm incidents. One incident led to an A&E attendance. Nonetheless, Bethany was still allowed to go on unescorted leave and on one such occasion advised staff she had been a victim of a crime during leave. She was subsequently put under constant 1:1 observations (Level 3).

Bethany was transferred to Thorpe Ward, Basildon on 15th January for continuing treatment. The ward did not receive all the relevant paperwork or case notes. Bethany was assessed by a psychiatrist upon arrival and put on a lower level of observations, requiring four observations an hour (Level 2), and a tentative discharge date of 22nd January 2019 was given.

Following a period of 24 hours with no incidents, Bethany’s observations were reduced, in accordance with the Trust’s policy, to Level 1 (one hourly observation). This was done without a full risk assessment or the involvement of a consultant psychiatrist. Bethany was found with a scarf tied tightly around her neck on the evening of the 16th January 2019.  Despite resuscitation attempts, she could not be saved.


The inquest jury heard a range of evidence on the issues arising in Bethany’s care, including the following.

Illicit substances and Diagnosis

The evidence indicated that cocaine made its way onto Ardleigh Ward, the Lakes Mental Health Unit, Colchester. It was accepted that not all the possible measures to prevent illicit substances being present on the ward were being carried out at the relevant time.

Medical staff told the inquest that until Bethany’s use of illicit substances was addressed, it was not possible to stabilise her mental health and for her to benefit from therapeutic intervention. However, despite being involved in her care for this purpose, the Dual Diagnosis Team were not offered a role in planning for Bethany’s discharge from hospital in August 2018 or following her subsequent admissions.

Record Keeping

There was evidence of very considerable problems in the record-keeping at EPUT psychiatric units. This included no discharge summaries being completed following either of Bethany’s discharges from hospital in November 2018 and cutting and pasting across records, leading to a misleading and incomplete discharge summary for 3 January 2019 and initial assessment undertaken on 15 January 2019.

Risk Assessments

Although the policy in place made clear that change in risk presentation and a transfer from one ward to another should lead to an updated risk assessment, no risk assessment was recorded after the afternoon of 11 January 2019, despite several self-harm incidents since that date and the fact that Beth was transferred from Peter Bruff Ward in Colchester to Thorpe Ward in Basildon on the 15th January 2019.

The jury found that it was probable that no risk assessment was carried out between the afternoon of the 11th January 2019 and leading up to Bethany’s death. They found this contributed to her death.

Further, a Consultant Psychiatrist stated that, had she known about these self-harming incidents, she would have carried out a review of Bethany. This did not happen. The consultant agreed that Bethany had “fallen through the cracks”.

Level of Observations

The Trust admitted that reducing Bethany’s observations to Level 1 on 16th January was completed without a full risk assessment taking place and without involving a Consultant Psychiatrist, which was inappropriate in light of Bethany’s risk factors and self-harming incidents.

Further, despite hearing evidence from the member of staff who claimed to have carried out Bethany’s last observation at approximately 7:05pm on the 16th January 2019, the jury did not believe him. It was found that this observation did not, in fact, take place.


The jury concluded that: “Bethany deliberately secured a ligature around her neck but the evidence does not fully explain whether or not she intended that the outcome would be fatal. Bethany Julia Lilley’s death was contributed by neglect.”

 The jury found that the following failings contributed to Bethany’s tragic death:

  • The admitted failures to ensure a full handover when Bethany was transferred on 15th January 2019;
  • The admitted failures in the decision to downgrade her observation levels on 16th January 2019;
  • Failings in the diagnostic formulation process, which had involved lack of collaboration between services involved, inadequate coordination between professionals and teams involved and inadequate evidence of documented handovers;
  • Failings in relation to record-keeping and documentation which had not been admitted and were only uncovered during the course of the inquest;
  • The failure to complete a risk assessment after 11th January 2019; and
  • The use of different systems of record-keeping, which prevented staff accessing relevant information.

The jury also found that the following failures were constituted neglect:

  • Documentation and record keeping;
  • Lack of risk assessments;
  • Inappropriate handover between Peter Bruff and Thorpe Ward;
  • Failure to place Bethany on the correct observation levels.

Lucy McKay, Spokesperson at INQUEST, said:Sadly Bethany is one of many people who have been failed and neglected by Essex University Partnership Trust and other Essex mental health services in recent years.

 “The conduct of Essex mental health services has been subject to significant public scrutiny, including extensive campaigning by bereaved families and now an ongoing independent inquiry.

 “This evidence of this inquest, both on the actions of Essex University Partnership Trust before and after Bethany’s death, are a reminder of just how urgent and necessary such scrutiny is. How many more must die before there is a real change in the culture and leadership in Essex mental health services?”

For more information on our Inquests services and how our team could help support your family, please contact 01603 620508 or visit our Inquests page.

This article was produced on the 21st March 2022 by our Medical Negligence & Inquests team for information purposes only and should not be construed or relied upon as specific legal advice.