An inquest jury has found that serious failures of risk assessment, communication, and the setting of observation levels contributed to the death of 19-year-old Brooke Martin. The jury returned their findings at the end of a 10-day inquest into Brooke’s death on 11 June 2019.
Brooke, who had diagnoses of Autism and Emotionally Unstable Personality Disorder, was detained under the Mental Health Act at Chadwick Lodge Hospital. Elysium Healthcare was in charge of the facility when Brooke died. The inquest jury concluded that Elysium Healthcare failed to properly protect Brooke. The jury outlined the following factors as contributing to her death: “The failure of staff to communicate information regarding an incident five days prior to her death.”
Full story in Milton Keynes Citizen, 1 July 2021