Hospital 'neglect' contributed to death of young mum who went missing from Sussex mental health unit

Thirty-two-year-old Rachel Jones became an inpatient at Langley Green Hospital’s Coral Ward in Crawley in April 2022 and was later found dead after going missing from the unit on May 6.

An inquest into the Crawley mum-of-one’s death heard that Rachel was struck by a train at Goffs Lane Footbridge in West Green, Crawley.

Following her death, Rachel’s family instructed expert medical negligence lawyers Irwin Mitchell to help secure answers and support them through the inquest.

Senior coroner Penelope Schofield recorded a narrative conclusion that Rachel took her own life, however, her death was ‘contributed to by neglect.’

She stated there had been ‘failures’ by the hospital to notify the nurse in charge when Rachel returned to the ward on May 6 asking for money, whereby she should have been reassessed by the nurse in respect of a period of requested leave.

There was also a failure to check on Rachel’s whereabouts and follow the AWOL policy when she hadn’t returned after 15 minutes. Ms Schofield recorded that it was ‘probable’ these ‘contributed to’ Rachel’s death.

She added there were also ‘missed opportunities’ by the hospital that ‘may have contributed to’ Rachel’s death. These were to ‘respond appropriately’ to a report on May 5 that Rachel intended to take her own life on discharge and also to update the risk assessment with concerns following events of May 5.

The Sussex Partnership NHS Foundation Trust, which runs Langley Green Hospital, carried out a Serious Incident Review and has now written to Rachel’s family offering its “deepest apologies that Rachel did not receive the care she should have.” It also confirmed that changes are being implemented following Rachel’s death.

Catherine Knight, a specialist medical negligence lawyer at Irwin Mitchell, representing Rachel’s loved ones including her mum Lorna, said after the inquest: “The past year has been incredibly difficult for Rachel’s family who are still struggling to come to terms with losing her so suddenly and in such tragic circumstances.

“They also had several unanswered questions over what happened that day and leading up to Rachel’s untimely death.

“We know nothing will ever make up for their loss, and the inquest has undoubtedly been tough for them, but at least they have been provided with the answers they deserve.

“Sadly, the hearing has highlighted worrying issues in the care Rachel received prior to her death. It’s now vital that lessons are learned to improve patient safety. We therefore welcome the trust’s pledge to make changes.

“People with mental health problems are some of the most vulnerable in society and it’s vital that they receive the best level of care at all times.

“We’ll continue to support Rachel’s loved ones at this distressing time.”

Since Rachel’s death, the Hospital Trust has admitted the “standard of care provided to Rachel was not as it should have been.”

As a result, the inquest was told that the following changes have been implemented:

The nurse in charge is to hold all information about patients, with the nurse in charge or a registered mental health nurse on shift being the only staff members able to grant leave;

Only substantive staff who have been through the trust’s full induction process can prepare risk assessments;

The leave log form has been updated to provide a fuller picture and ensure this captures the time a patient is due to return;

Staff have been trained to cross-check the leave sheet with the observations sheet to ensure that a patient who hasn’t returned at the expected time is flagged as missing as soon as possible, and in line with AWOL policy;

Updating of the entire AWOL policy in conjunction with Sussex Police as a result of lessons learnt from Rachel’s death.

Rachel was a former carer who left her job when she became mum to Tommy, four. Following her death, Tommy is being cared for by his dad, who was also Rachels’s partner, Tom De Feria, 32, and Lorna, Rachel’s mum.

Lorna said: “Since losing Rachel, there’s a huge hole in our lives. She was the best daughter, sister, partner and mum, and it’s heartbreaking that she’s no longer with us.

“Her mental health had been a struggle for a few years, but we were hopeful that she was getting the help and care she needed to be able to return home.

“The day Rachel died will be etched into my memory forever, and the pain is still as raw as it was back then. Not a day goes by when we don’t wish she was still here, and to know that she didn’t get the care she should have is really tough to accept.

“We would do anything to have Rachel back, but we know that’s not possible, and the inquest has been upsetting for us all. The only comfort we can take from it is that we have some answers.

“All we can hope for is that mental health services improve to prevent other families from suffering like we have.

“Our priority now is to raise Tommy how Rachel would have wanted and make sure that he knows every day how much she loved him.”