Summerlands ward where woman, 20, died 'not properly secured', inquest jury finds

An acute mental health ward failed to adequately supervise and secure a room where a 20-year-old woman died, an inquest jury has found.

Jessica Powell died on 22 August 2020 following the incident three days earlier on Rowan Ward at Summerlands Hospital in Yeovil.

She died while trying to climb through one of the windows on her ward, an inquest into her death heard.

The hearing took place at Wells Town Hall from 9 to 16 December 2024 before assistant coroner Vanessa McKinlay of Somerset Coroner’s Court.Ms Powell had a diagnosis of emotionally unstable personality disorder (EUPD), but the jury heard that she was also a "determined, intelligent, funny and loving" young woman.

Her parents said in their statements that Jess had made significant academic progress while at Summerlands – she had got her Maths and English GCSEs and started studying for a degree.

The inquest heard Jess was first referred to mental health services as a child.

She spent a large proportion of her teenage years as an inpatient in various mental health units across the country and had been admitted to 11 hospital units before she turned 18.

After she was transferred to adult mental health services, her inpatient admissions were at Rowan Ward, which was closer to home.

Before her final admission to Rowan Ward, she spent some time at a supported placement, Christopher House, where her parents raised concerns.

The inquest heard that Jess’s attempts to live in the community had not worked.

From October 2019 until she died, Jess was detained on Rowan Ward under section three of the Mental Health Act.

The jury heard that, as a result of her EUPD, Jessica could be impulsive, struggle to regulate her emotions and use self-harm to manage her distress.

They were told that her self-harm was extensive and even life threatening at times. She had a history of absconding, including directly from Rowan Ward and from A&E.

The jury heard that Jess was subject to various risk management measures during this final admission, including restrictions on leave from hospital and on use of her phone and laptop, removal of possessions, and different levels of observations.

Although Jess could have periods of good days, these could often end with a significant self-harming incident. It was reported in evidence that her mood could be very changeable.

In her parents’ evidence they explained how they regularly spoke with staff to make them aware of their concerns.

They told staff of their concerns that Jess might die, and they had asked about her being moved to a psychiatric intensive care unit (PICU).

Towards the end of May 2020, Jess absconded by escaping through a window in a communal area.

The window was subject to restrictors designed to restrict the opening to 10cm. The restrictors were subsequently noted to be faulty.

In early June 2020, Jess was given a place in a specialist personality disorder unit in Cambridge called Springbank.

The unit was operating with limited beds due to the Covid-19 pandemic, so Jess faced a wait of a few months.

Jess’s parents reported contacting Springbank in advance of the move.

They were concerned to hear that the aim would be to remove Jess from being sectioned within a relatively short timeframe, and that if Jess went missing from Springbank police wouldn’t start looking for her until 48 hours had passed.

There was varying evidence from Rowan Ward staff as to the extent to which they were aware of these plans.

Over the summer, Jess took more extreme measures to harm herself and her parents became increasingly concerned.

The jury heard that staff recorded in notes that they considered that Jess was likely to die, and that an acute ward was not appropriate for her.

On 18 August 2020, Jess received confirmation that her move to Springbank would take place on 24 August. She was reported to be nervous, excited, and scared.

The jury heard that on 19 August 2020, Jess was seen at about 10.20pm, when she came to collect her phone from the ward office.

Shortly after this it became apparent she had not had her evening medication. Staff commenced a search of the ward and garden.

Mr Stephen Aduachie, a healthcare assistant, stated in evidence that he searched a therapy room, which was in a slightly more secluded area of the ward.

That evening, this room was being used by another patient. There was a sign on this door stating: “DOOR TO BE LOCKED WHEN NOT IN USE.”

The inquest heard that records showed that that patient had been in the therapy room at 9.58pm, but the same record did not show that they were in the room after that time.

When Mr Aduachie looked through the window in the therapy room door, the lights were off and the door was locked. The door could be locked from the inside.

Mr Aduachie was unable to see all parts of the room. When he opened the door, he saw Jess in a window. She was facing outwards with her lower body out of the window and her upper body inside.

This window was also subject to restrictors, such that the opening was restricted to 10cm. The room was on the ground floor.

Mr Aduachie’s evidence was that he could not find a pulse. He activated an alarm and called for help, before running around the outside of the building to get to Jess from the outside.

He pulled the window open and lowered Jess to the floor. Jess received CPR and was subsequently taken to hospital, where she sadly died from her injuries on 22 August 2020.

The jury said that Rowan Ward failed to adequately supervise and secure the Therapy Room which was fitted with windows that Jessica, a frequent absconder, might reasonably believe she could escape through.

They went on to conclude that Jessica deliberately tried to climb through the window and it was not her intention to end her life by doing so.

Family say they 'weren't taken seriously'

John Powell, Jess’s father, said: "We are pleased that the jury recognised the very serious ways in which Jess was failed on 19 August 2020.

"We have long felt that those involved in her care became complacent. They did not appreciate how dangerous Jessica’s behaviour could be and how carefully she had to be looked after.

"We were portrayed as interfering neurotic parents, but everything we did was an effort to keep her safe and alive. We raised concerns time and time again.

"Jess changed my entire mindset on mental health; I used to think that people who struggled with their mental health were weak, but Jess was the strongest person I’d ever met.

"It seemed impossible to continue with life with everything that was going on in her head and yet she persisted; she loved her family, she studied hard for her degree, she was exceptional.

Victoria Powell, Jess’s mother, said: "We have waited four years for this hearing, and it’s a huge relief that the jury agreed with us that Jess was let down. I am devastated by Jess’s death.

"We haven’t been able to grieve properly because we have been waiting for this inquest. It has felt like a bad dream.

"We tried our hardest to keep her safe, but we weren’t taken seriously. Over the last months of her life Jess’s self harm became really severe and determined, and I was terrified.

"I was worried about what would happen next. It felt like I was calling the ward constantly.

"I can’t understand how she got unsupervised access to the room that she was found in; even after the explanation that we have heard in the hearing, I can’t see how they let this happen.

"Throughout Jess’s illness it seemed that the professionals all thought they knew her best, but they didn’t. I was her mother - I knew her best."

Ruth Mellor, of Deighton Pierce Glynn, the solicitor representing Jess’s family, said: "The outcome of this inquest confirms what Jess's family have suspected for four years; that Jess posed risks to herself that weren’t managed carefully enough, and that this played a role in her death."

Statement from Somerset NHS Foundation Trust

Jane Yeandle, Somerset NHS Foundation Trust’s service group director for mental health and learning disabilities, said: “Our thoughts are with Jessica’s family and loved ones.

"She was loved and intelligent and we are very sorry that she died as a result of an incident in our care.

“Following Jessica’s death, we commissioned an independent report to look at her care and treatment, the layout of the ward, and to answer her family’s questions.

"It provided recommendations on management of the physical ward environment and access to different areas.

“We took forward all of the report’s recommendations but will now look closely at the inquest’s conclusion to see if there are further actions we need to take.”