Case Update – The Inquest of Zoe Clark

On Friday 23 April 2021, the inquest into the death of Zoe Clark reached a conclusion.  The jury concluded that the care she received from Devon Partnership Trust both in the community and in the hospital, was inadequate.  Hospital staff failed to appropriately assess, monitor and appreciate the risk to Zoe of taking her own life.  These failures were all said to “probably cause or contribute more than minimally” to her death. 

Zoe was 22 years old when she died.

Why was Zoe Clark admitted to the Haldon Unit?

She was diagnosed with anorexia nervosa in 2010 and had multiple admissions to hospital. Zoe also suffered from depression.  She was admitted to the Haldon Unit, Exeter between February and June 2017.  She was then discharged home subject to a Community Treatment Order (CTO); she was subsequently re-admitted to the Haldon Unit on 31 July 2017 after being recalled under the Mental Health Act for a breach of her CTO.

Zoe died early in the morning of 22 August 2017 whilst an inpatient on the Haldon Unit.  At the time she was the subject of hourly observations.

While in the community Zoe only saw her Care Co-Ordinator once despite her Section 117 plan saying that there should be weekly meetings. The plan also included weekly visits to her GP so that she could be weighed – these never took place.  The inquest heard that the Care Co-Ordinator left several voicemails but did not attempt to contact Zoe using other means or talk to her parents who could have helped to arrange meetings.

On one occasion Zoe was left waiting outside Sainsburys whilst the Care Co-Ordinator was in the café inside.  Zoe did attempt to contact her but in evidence the Care Co-Ordinator accepted that her phone was either out of battery or switched off so the meeting never took place.

Zoe received only minimal support during her time in the community and, ultimately, her BMI fell to such an extent that she was readmitted to the Haldon Unit.

Events leading to Zoe’s death

She was a patient on the Haldon Unit for just over three weeks before she died.  The inquest heard that while in the Haldon Unit she received only 30 minutes of formal psychological treatment as part of a group therapy session.  Zoe’s plan for treatment was for psychological support to be provided by a psychologist from another team who Zoe knew well.  However, the psychologist was not told of the plan for him to provide therapy on the ward and the only contact he had was an email from the Care Co-Ordinator suggesting they meet to make plans for Zoe’s discharge back to the community.  During her admission Zoe received no 1-2-1 psychological treatment.

During her admission, Zoe self-harmed a number of times.  She smashed a mirror and two lamps, cut her arms and banged her head against the wall.  Despite this escalation, she received no formal psychological input as reflected in her medical records.

On 18^th August, Zoe told nursing staff that she was feeling hopeless, that she felt “defeated” by her eating disorder and that she would “always be anorexic”.  It was also recorded that she had been banging her head.  These concerns were not escalated and there is no record of anyone talking to her meaningfully about thoughts of self-harm or suicide.  It is hospital policy that all such discussions should be documented and risk assessments and care plans should have been updated with relevant information with this relevant information.

Zoe’s Named Nurse said she was often the only nurse on duty and would prioritise updating the Handover Shift summaries over the risk assessment and care plans.  Unfortunately, Devon Partnership Trust were only able to locate two Handover Shift summaries, one of which was updated after her death.

Zoe’s parents were not told about any of the occasions when she self-harmed or talked about feelings of hopelessness.  After one incident of self-harm the family therapist left a voicemail saying that everything was “ok” and was going according to plan and that the family could call the ward if they had any concerns.

At the time she died Zoe was on hourly observations.  Evidence was heard that she had been seen by a Healthcare Assistant at approximately 1am and was then found by a nurse at approximately 1.04am.  A member of staff called 999 at 1.07am.  When the paramedic arrived at 1.11am he used a defibrillator to try and revive Zoe.  It is unclear why the defibrillator on the ward had not been used by staff members although a nurse gave evidence that the ward’s defibrillator had been delivered to Zoe’s room and found in the doorway.

The jury saw a letter that had been written to Zoe from the ward manager on the day before she died that was to be delivered by hand.  The purpose of the letter was to tell Zoe that she would be responsible for any further damage to hospital property.  Although the letter does accept that Zoe had previously damaged property when distressed there was no mention of concerns for Zoe’s wellbeing.

What was the jury’s verdict?

The jury found that Zoe deliberately chose to suspend herself by her dressing gown cord but that the evidence did not fully explain whether or not she intended the outcome to be fatal.

The jury further concluded that the treatment in the community and on the Haldon Unit was inadequate and this failure to provide appropriate care and treatment did “probably cause or contributed more than minimally to Zoe’s death”.

They also found that the healthcare professionals did not appropriately assess, monitor and appreciate Zoe’s risk of suicide, and this failure to appreciate the risk did “probably cause or contributed more than minimally to her death”.

Statement from Zoe’s Family

“While we welcome the inquest’s findings it will not bring back Zoe, a wonderful daughter, sister and auntie.  There will never be another Zoe; she was kind, witty and hardworking.  She is so missed by us all and her sister is dejected that she will never be known by her nephew and niece, who she would have loved and adored.  Our hearts are broken.

We have heard so much concerning evidence in the inquest.  For whatever reason, the care and treatment Zoe needed and should have received in the community was not provided, and when she was in the Haldon Unit there appeared to be confusion over who was meant to be providing psychological therapy – so none was provided.  We feel her actions were considered “this is just Zoe“, rather than being properly investigated.

We were a close family and were always there to support Zoe.  She talked to us.  However, we were not contacted by anyone when Zoe started self-harming, or when she started talking about feeling of hopelessness.  As we were not told about what was going on, we missed the chance to support and help her, and just tell her we were there for her and loved her.  Instead, we feel we were shunned and our concerns were ignored, as we feel they had been on so many other occasions over the years that Zoe was under the care of the Devon Partnership Trust.

We had always felt that the Haldon Unit was not suitable for an eating disorder unit.  At the time of Zoe’s death there was no secure outdoor space where she and the other patients could spend time, and hospital policy meant that no-one was allowed to smoke or vape anywhere within the hospital grounds.  We were pleased to hear that patients in the Haldon Unit now have a secure garden which they can enjoy and believe it is vital a secure outdoor space will always be available to them.

We would implore Devon Partnership Trust to learn from Zoe’s death and to ensure that there are safe and effective measures in place to protect those in their care.”

Comment from Gary Walker, Enable Law

The family were represented throughout the inquest by Gary Walker of Enable Law.  Gary said:-

“The inquest raised some very concerning issues regarding the management and provision of Zoe’s care and treatment, both in the community and during her admission on the Haldon Unit.

I have represented many patients who suffer from eating disorders and this inquest does raise some broader issues.  I often hear from families who been overlooked and ignored and have not been able to be involved in the care and treatment of their loved one.

We did hear evidence that changes have been made, and families and patients are now invited to weekly Clinical Review Meetings and there is a more robust system in place for recording and monitoring incidents and a patient’s feelings.  In my opinion this is a significant and important change that will allow patients and their families to be involved in the provision of care and support and reduce the risk of another tragic outcome.

I have been involved in other cases where the door frame was used as a ligature point and I was pleased to hear that Devon Partnership Trust are in the process of installing door-top sensors on all bedroom doors.  The technology is relatively new but I believe it important that all units and hospitals whose patients are at risk of suicide review their risk assessments and strongly consider installing door top sensors.  This could save lives.

I am pleased to see these changes are happening but hope that Devon Partnership Trust remains vigilant and continues to strive to provide a safe and therapeutic service.”