Bethany Lilley experienced complex mental-health difficulties and had a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and a history of psychiatric inpatient admissions. During her final inpatient admission from 9 January 2019 she continued to display high risk and suicidal behaviour and was put on observations suitable for a high risk patient. She was transferred to Thorpe Ward, a treatment ward in Basildon on 15 January. However, the ward did not receive a full handover or all the relevant case notes and her level of observations was reduced to the lowest level. On the evening of the 16 January 2019, she was found unresponsive with a scarf tied tightly around her neck. Despite resuscitation attempts, she could not be saved. She was 28 years old at the time of her death.

After hearing evidence for almost three weeks, a jury at Chelmsford Coroner’s Court 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.”

Essex Partnership University NHS Foundation Trust made a number of admissions regarding her care prior to the inquest, including that there had been a failure to ensure a full handover when Bethany was transferred on 15 January 2019 and a failure in the decision to downgrade her observation levels the following day. In addition, the jury found that failings in diagnostic formulation, record-keeping and documentation, risk assessment and the use of different systems of record-keeping contributed to her death.

HM Area Coroner Sean Horstead is considering whether a Prevention of Future Deaths Report is to be made.

Jonathan Metzer was instructed on behalf of Bethany’s family by Jenny Fraser of Fosters Solicitors. Emma-Louise Fenelon was instructed on behalf of EPUT by Sophie Barbour of Hempsons.

Read more information about the inquest here.