Jessica Elliott appeared on behalf of the family of Morgan Rose Betchley, who died on 9 March 2023 whilst receiving treatment on an acute mental health inpatient ward at Meadowfield Hospital. An inquest into her death was held between 11 and 22 November in Horsham Coroner’s Court, and the jury concluded that her self-inflicted death was a “cry for help”.
At the time of her death, Morgan had been receiving treatment over a period of weeks from numerous teams and services, and had been admitted to inpatient wards at Meadowfield Hospital on three separate occasions. She had been detained under section 2 of the Mental Health Act on three occasions, had endured two lengthy admissions to A&E, and had spent a night in police custody.
The two-week inquest heard evidence from members of Morgan’s treating team at Meadowfield hospital. The jury concluded that multiple failings contributed to Morgan’s death, including “failures relating to admission process, understanding of existing diagnoses, risk management, record keeping, family involvement and discharge planning” which “prevented Morgan from receiving access to services she needed at the time”. They considered it probable that if policies and procedures had been followed “Morgan would have benefitted from a level of care more closely aligned to her complex needs, including her diagnosis of Autism”.
The jury also found that Morgan’s attempts to apologise after an incident of assault “were not handled in a professional manner” leading to a “fractured professional relationship” and a situation that was “made unnecessarily stressful for Morgan”.
A Regulation 28 report to prevent future deaths was issued in relation to environmental risks on the ward.
Jessica was instructed by Charlotte Haworth Hird, of Bhatt Murphy.
For news coverage of the case, please see here.
