Coroner demands action from health trust after death of woman at hospital 250 miles from home

A coroner is demanding action is taken by a health trust following the death of an autistic woman who was found unconscious at a psychiatric hospital more than 250 miles from her home. 

Lauren Bridges, 20, was an inpatient at the Priory's Cheadle Royal hospital, Greater Manchester, at the time of her death in February 2022.

In September, a jury inquest at South Manchester Cororner's Court in Stockport returned a conclusion of misadventure.

The hearing was told Lauren, who was from Bournemouth, had been found unconscious in her en-suite bathroom at the hospital at around 10pm on February 24.

She was taken to Wythenshawe Hospital, with her family making the six-hour journey from Dorset to be with her.

A clinical decision was made, in consultation with Lauren's mother Lindsey and her loved ones, to end her life support and she died two days later.

The jury inquest heard four weeks of evidence before concluding that Lauren, who had been diagnosed with Autism Spectrum Disorder and Emotionally Unstable Personality Disorder, did not intend to take her own life.

Jurors also found there were 'missed opportunities' to find her a bed closer to home during her seven-month admission.

Now, coroner Andrew Bridgman has written to Dorset Healthcare University NHS Foundation Trust raising his concerns in a prevention of future deaths report. He states that the trust's "standard of record keeping was inadequate".

He speaks of his concern that an 'Out-of-Area Hospital Overview' document was not updated "timeously and correctly", adding that "it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place".

The report states: "During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate.

"Among other things, Lauren’s name did not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU (psychiatric intensive care unit).

"There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the five months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim."

The corner's report then goes on to note that during the inquest, the health trust made the following admission: "Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed."

In response, the coroner added in his report: "Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of this omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest. In my opinion there is a risk that future deaths will occur unless action is taken."