News and current affairs magazine Private Eye has highlighted the concerns of a coroner over a woman’ death after she twice left the psychiatric unit in Hove where she was being detained.
West Sussex coroner Penelope Schofield spoke out after a jury returned a verdict of unlawful killing in the case of 21-year-old Brighton University student Janet Müller.
Miss Müller left Mill View Hospital, in Hangleton, twice in just over 12 hours. The next day her body was found in the boot of a burning car.
The criticisms at the inquest last month have been addressed in a statement by Sussex Partnership NHS Foundation Trust which runs Mill View and the hospital’s boss apologised.
Under the head-line “Care-less killing”, Private Eye said: “Twice in one day business studies student Janet Müller, 21, was able to walk out of the Sussex psychiatric unit where she was being detained for her own safety.
“The first time she was taken back by the police after being seen in a distressed state wandering in a field. The second time she did not return.
“Her beaten body was found in a burnt-out Volkswagen the following day.
“Last year Christopher Jeffrey-Shaw, who admitted setting fire to the car, was cleared of murder but convicted of manslaughter after he claimed to have been involved with drug dealers who borrowed his car for a robbery which went wrong.
“Jailing him for 17 years, the judge told him that while the jury had found he was not responsible for the head injuries Janet had suffered, ‘you did not have the human decency to check if the person in the boot of your car was dead or alive.’
“Last week an inquest jury issued a narrative verdict suggesting Janet’s death had been wholly preventable.
“She should never have been able to walk out of Mill View Hospital in Hove once, let alone twice.
“The jury concluded that Janet had been unlawfully killed but found Sussex Partnership NHS Foundation Trust guilty of a series of failures in her care.
“These included not having enough staff on duty, incomplete and contradictory medical records and risk assessments, a lack of communication between staff and failing to make safe a garden wall over which it was known patients could flee.
“The jury had heard that two others had absconded since Janet’s death in March 2015.
“West Sussex coroner Penelope Schofield said that while improvements had been made ‘patients are still absconding and it does concern me that patients are not being protected’.
“Janet had come to the UK from Germany to study international business management at the University of Brighton in September 2012.
“She had been taken to Mill View suffering a psychotic episode and during her ten days on the ward repeatedly told staff she wanted to leave.
“On 12 March she disappeared at some point after 7.45am, later saying she had climbed over the garden wall.
“Despite Janet being on 15-minute observations, the senior nurse on the ward was not told of her disappearance and a search was not instigated for more than an hour.
“One Janet’s return a senior manager said she should be placed on constant observation and that the door to the garden should be locked.
“Instead, Janet was allowed into the garden on her own and, it appears, was only checked around once an hour.
“Despite being seen to have become distressed at around 9pm, nothing was done to ensure Janet remained on the ward. The one qualified nurse on duty was busy dispensing night-time medication.
“Last seen on CCTV in the early hours before her fatal encounter with Jeffrey-Shaw, Janet’s body was recovered later that afternoon.
“Deborah Coles, director of campaigning charity Inquest, which supported Janet’s family, said hers was the fourth death in recent years at Mill View which had attracted criticism: ‘Although she was tragically killed by a stranger, the failures in Janet’s care were not isolated incidents, which begs the question had they acted on previous recommendations would Janet still be alive today?’”
Sussex Partnership’s clinical and service director for Brighton and Hove, Gurprit Pannu, said: “I do not underestimate how difficult and painful this inquest must have been for Ms Müller’s family and friends.
“I want to offer my sincere condolences on behalf of the Trust. I also want to say sorry.”
Dr Pannu, a consultant psychiatrist at the trust, said: “Ms Müller was a vulnerable young woman under our care who should not have been able to leave hospital in the way she did.
“We have made changes following our own internal investigation which has included improving our security arrangements at Mill View Hospital.
“Ms Müller’s death was also included in an independent review of homicides we commissioned and published last year to make sure we embed the learning from incidents in a way that helps us improve the services we provide.
“That said, the fact remains that Ms Müller left hospital without permission while under our care.
“As clinical director responsible for our services in Brighton and Hove, I take personal responsibility for making sure we reduce the risk of anything like this happening again.
“As an NHS trust, we will reflect on the points the coroner has made today and make sure we respond to the concerns she has raised.”
The deaths of patients of Sussex Partnership NHS Foundation Trust who, in conjunction with BHCC ASC are “placed” in revolting private “B&B temporary, emergency” accommodation also needs to be investigated. Caroline Lucas has tried to draw attention to this but has been rebuffed and both parties are in denial. There should be an audit of all such deaths in the last 10 years and the associated coroners records.