Chris Slater examines the desperately sad case of Lauren Bridges following an inquest into her death at the Priory in Stockport. A jury concluded she didn't intend to take her own life - and that there were 'missed opportunities' to find her a bed at a unit closer to her home down south
On the evening of February 24, 2022, Lindsey Bridges received the first of two phone calls which will haunt her forever. Her daughter Lauren was on the line. A straight-A student, she was adored by her loved ones - kind, considerate and 'the most beautiful person inside and out'.
She wanted to go to university and dreamed of becoming a doctor or a nurse so she could help others. The bitter irony that, in her mother's words, she was 'horribly failed' by the mental health system is all too clear. Lauren, 20, was autistic and had been diagnosed with a personality disorder. There were fears for her safety as her mental ill-heath worsened. Lauren was sectioned under the Mental Health Act and transferred to a psychiatric hospital in Stockport.That facility was more than 250 miles away from her family in Bournemouth on England's south coast. Lauren was admitted to a secure psychiatric intensive care unit at The Priory's Cheadle Royal Hospital, during the later stages of the Covid pandemic in 2021. It was her ninth stint in hospital in under four years. A number of those placements were a significant distance from home. It was meant to be a short-term placement. Yet seven months later, she was still there. Lauren was distressed at being so far away from home for such a long time. During the call to her mother, Lauren sobbed, begging and screaming for help. She wanted to leave the Stockport unit. Hours later, Lindsey received another call. Lauren, she was told, had been found unconscious in her en suite bathroom. "As soon as I saw the phone ring in the middle of the night, I just knew something had happened to Lauren," she said. She had suffered a cardiac arrest, having hanged herself, and had been rushed to Wythenshawe Hospital. Lindsey and her family frantically made the six-hour journey to south Manchester to be at her bedside. "Those hours travelling to be with her and then in hospital will stay with me forever," she said. On February 26, the family had make an unthinkably tragic decision. Her life support was switched off due to the extent of the hypoxic brain injury she had suffered. Lauren gave the gift of life to others in need, with her organs put up for donation. Lindsey described it as 'the hardest thing [she will] ever have to do and something [she will] never get over'. The 44-year-old had become a fierce autism and mental health advocate and had documented her family's 'journey through the mental health system' on social media. She built up a large online following, penning blogs and launching a podcast called 'Bridges Over Troubled Waters.' Lindsey vowed to honour her daughter's memory. She wanted answers about her final days - and hoped an inquest would provide them. A 'painful and gut-wrenching month' An inquest into Lauren's death originally got underway in February this year. A jury was sworn in after Lauren's family made the long journey to Stockport. Lindsey entered the witness box on the first day of the scheduled fortnight-long hearing. In dramatic scenes, proceedings were suddenly halted and abandoned before the third day of evidence got underway. The family's legal team later said it had become clear the inquest could not be completed in the allocated two-week slot. It was adjourned to the summer. Prior to the second hearing, which began on August 9, Lindsey said it would be a 'painful and gut-wrenching month', but that it 'had to be done'. She walked into court one at Stockport Coroners' Court each day, arm in arm with her partner - Lauren's step-father, James Hinton. Often visibly emotional, Lindsey and James had two endure hours of detailed, harrowing evidence about Lauren's final days; her care at the Priory; and the circumstances leading to her death. After four weeks of evidence, the jury recorded a conclusion of misadventure on Friday . They concluded Lauren did not intend to take her own life and that the incident was a 'cry for help due to a lack of family contact', as were previous acts of self-harm. They also identified that beds were available near her home down south - before she was moved here. There were 'missed opportunities' for Lauren to be moved closer to her family, jurors concluded. Lindsey said the jury's conclusions left her family 'devastated'. They 'believe Lauren would still be with [them] if she had been brought closer to home', she said. Following the hearing, Lindsey said 'sending mental health patients hundreds of miles away from home to receive treatment does not work', adding that 'vital changes' are needed in the way people - particularly young women - are cared for. She has called for 'Lolly's Law', to further protect those with autism and learning disabilities within the mental health system. The heartbreaking loss that had a 'profound effect' Heartbreakingly, it wasn't the first tragedy the Bridges suffered. One of Lauren's two brothers, Alfie, died from mitochondrial disease - a rare genetic condition - when he was just two-years-old. Her sibling's suffering had a 'profound effect' on Lauren. She was first referred to Child and Adolescent Mental Health Services aged 15, suffering from severe anxiety and OCD. She was diagnosed with autism at 17. Lindsey said 'the opportunity for early intervention was missed for Lauren' as her mental health began to deteriorate. She was first admitted to a psychiatric unit in October 2018, on a voluntary basis, as she was about to turn 17. According to Lindsey, 'it is a reflection of our mental health system that she never came home for good'. Over the following years, she was admitted to units seven more times. Her ninth admission was to the Priory in Cheadle in the summer of 2021. The inquest was told she had a 'dual diagnosis' of Emotionally Unstable Personality Disorder and Autism Spectrum Disorder . One specialist later questioned whether she had EUPD at all, saying there was a lot of 'very high-level diagnostic overshadowing' between the two. Lauren's consultant agreed. In June that year, the decision was made to transfer her from a 'locked rehabilitation unit' at the Priory's Pelham Woods hospital in Dorking to a PICU at Cheadle Royal. The inquest heard staff at Dorking felt they 'couldn't manage' her due to the 'risk' as 'there was increasing self-harm'. Commissioning of mental health services for residents in Bournemouth is the responsibility of the Dorset Integrated Care Board , then known as the Clinical Commissioning Group . Jurors were told that body commissions services from Dorset HealthCare NHS Foundation Trust, which provides inpatient services in the county. Once a PICU was required, it was the trust's role to 'find and fund' a placement, which it did - at the privately-run Cheadle Priory. In their conclusion, jurors said there were available beds in Dorset in July, which may have prevented the need for Lauren to go to Cheadle, but that they were not offered. Lindsey said she was 'extremely worried' about the plan to move her daughter so far away. She claimed the family was 'excluded' from decision-making and that Lauren, who was 'distraught' on hearing the news, was given an hour to pack her bags before being moved on July 23. 'We didn't get the opportunity to say goodbye' "We had no time to visit her again and didn't get the opportunity to say goodbye," Lindsey said. "It broke her and our family. As parents, we couldn't understand why they thought she would have benefitted being so far from her family." The intention was that she would spend a 'short time' - likely six to eight weeks - in Greater Manchester, her consultant at Cheadle Royal, Dr Hari Kumar Sholinghur said. Once that risk had reduced, the plan was to move Lauren closer to home. At a ward round on September 3, the doctor said she was ready to be 'stepped down'. Dr Sholinghur said the 'long-term' goal was to secure Lauren a place at a rehab unit to continue treatment, but in the short term, an 'interim plan' to move her to a general acute ward was drawn up. The hearing was told there was a 'delay' in discharging her - the background to and reasons for which was, according to the coroner, the 'overarching issue' of the inquest from the outset. According to one professional, there was also a 'degree of uncertainty about what was being sought' for Lauren. Mark Harris, of the NHS Dorset Integrated Care Board - who, at the time, was head of mental health and learning disabilities at what was then the Dorset Clinical Commissioning Group - told the first inquest: "Changes in presentation and the nature of that created challenges in trying to find the right placement for Lauren." Dr Sholinghur agreed there were 'fluctuations' in her condition and her risk during her stay and that there were times a 'side-step' to another PICU closer to home was deemed more appropriate. At all times, he said 'the main thing [they] were looking at was her being away from home'. One specialist said being on the Pankhurst Unit, through no fault of staff, was causing Lauren 'iatrogenic deterioration' - a medical term for harm caused by mental health treatment - as the ward was 'wholly ill-equipped to meet her needs'. Dr Christopher Ince was asked by Lauren's solicitor to complete a report ahead of an upcoming mental health tribunal in November 2021 - four months before her death. For people with autism, inpatient treatment was 'rarely beneficial' and there was a 'significant risk it becomes counter-productive' as the environments produce 'significant sensory demands', he said. Dr Ince said there were times he assessed Lauren and saw her 'visibly wince' when alarms went off or doors were slammed. "Inpatient psychiatric wards are noisy, busy, unstructured environments," he said. "They produce significant sensory demand. "They are often associated with high levels of emotional distress due to the nature of the patients that are there. They are often understaffed and inappropriately staffed, due to the nature of the demands of the patients that are there." The inquest heard Lauren was deemed to be at increased risk of 'exploitation from others'. Dr Sholinghur said: "Lauren was a person who wanted to please others, wanted to be accepted. There are other peer group patients on the ward who may take advantage, that's why she could have been more vulnerable than others." Mr Bridgman referred to three incidents in which there 'may have been collusion' between Lauren and another patient, seeming to 'relate to self-harm'. A second, in January 2022, may have involved 'colluding behaviours' regarding the 'physical assault of another peer', the coroner added. The next month, it was reported Lauren had pocketed medication and passed it to someone else. Asked if he thought she was being exploited, Dr Sholinghur said it is 'something that can happen in... wards and has happened'. 'Living in fear' Lindsey said 'living with very unwell patients had a detrimental impact on Lauren', that she was 'regularly threatened' and 'lived in fear' of other patients, including one she claimed threatened to kill her. She said the family had 'significant concerns about the care she received at Cheadle Royal, particularly in relation to night agency staff and the lack of compassion shown by staff'. Lindsey said Lauren 'struggled at night' and that night staff 'offered no support'. She claimed that on one occasion 'all her possessions were taken away, including all her sensory items' and that she was 'told she had to earn them back'. Dr Ince suggested Lauren should have been discharged directly from the PICU back into the community, for example at supported living accommodation with specialist support. But he said no one involved in her care ever contacted him to discuss that matter. The hearing was told this could take a 'long term' to secure and may even have to be built or set up especially for Lauren. Dr Ince argued clinicians overseeing her care had ample time to do this. "Lauren's needs were not unknown," he added. "This was not her first admission. She had been admitted to hospital before. The process of discharge should have commenced at the point of admission." By February 2022, Lauren remained at the unit as her condition deteriorated. The jury was told Dorset Healthcare made an 'admission' that 'there were shortcomings in trust systems in recording the identity and relevant circumstances of its out-of-area patients and the processes for assessing those patients'. "As a result, there may have been missed opportunities to offer Lauren a bed," it was said. The coroner asked the jury to consider if 'the distance from home was a contributing factor in the deterioration' of her mental health - and, if so, if 'that deterioration of Lauren's mental health was a contributing factor to her actions' on February 24. If jurors found it was, they could examine and comment on the 'reasons for prolonged admission or delayed discharge', Mr Bridgman added. Delivering their findings, the jury foreperson said 'Lauren's desire to be close to home was a consistent theme in her admission'. Dorset Healthcare, they said, 'did not recognise the exceptional circumstances of Lauren being over 250 miles away from home' - and that their communication was 'inadequate'. Jurors concluded beds were available in Dorset for more than half the days of Lauren's admission, but that she 'was not actively considered for these beds'. These missed opportunities contributed to incidents of self-harm, they said. 'She didn't want to die... she wanted to come home and get better' As Lindsey put it: "Lauren didn't want to die. She was desperate to escape a hospital that was making her mental health worse. She wanted to return home to her family and get better." Mr Bridgman outlined how the Priory has a relationship with 42 integrated care boards or health bodies and that many use different systems. He questioned how streamlined information is passed between bodies and independent providers and asked if there was room for improvement. At the conclusion, he said they now have a 'fairly robust' delayed discharge protocol in place. Dorset HealthCare has 'recognised it would be apt to have a care coordinator with sole responsibility for out-of-area patients which will ultimately improve its management and oversight of its patients out of area', he said. Lauren's medical cause of death was given as 1A) hypoxic brain injury; 1B) cardiac arrest; and 1C) hanging. The jury concluded she did not intend to take her own life, recording a conclusion of misadventure, rather than suicide. Ultimately, Lauren's family felt her continued detention was crucial to what later happened. Immediately following her daughter's death, she said: "Being an inpatient has robbed me of my daughter, my son of his sister, my parents of their granddaughter and most importantly it has taken away Lauren's life." She has since called for her daughter's death to be a catalyst for change. "I want to make sure that no family has to go through what we have experienced," she said outlining plans for 'Lolly's Law'. Lindsey has called for: "I believe if my proposals were already in place, my daughter would still be alive," she said as she launched a petition which has now been signed more than 220,000 times. 'When Lauren needed help the most, she was let down' Following the inquest, Lindsey said: "Despite her challenges, she worked so hard to be heard, to be understood and get home. However, we are left feeling that when Lauren needed help the most, she was let down. "Lauren initially went into hospital voluntarily aged 17. It is a reflection of our mental health system that she never came home for good. Lauren was moved from one out-of-area hospital to hospital to another, getting worse and worse over time. Our concerns and Lauren's requests to come home were ignored. "Lauren gave so much joy and happiness to everyone who knew her. We'd do anything to still have Lauren with us. We thank the jury for returning a verdict of misadventure and for recognising the failings in Lauren's care. "Our lawyers had to fight hard to get these answers through the legal process. We hope that lessons will be learned from how Lauren was horribly failed. It is vital that changes are made to how people with mental illnesses and autistic people, particularly younger women, are cared for. "The system we currently have isn't equipped to deal with our most vulnerable. Sending mental health patients hundreds of miles away from home to receive treatment does not work. We are devastated to learn that there were available local beds before Lauren was moved so far away and that there were opportunities missed to bring her home. We believe that Lauren would still be with us if she had been brought closer to home. “Mental illness doesn't discriminate - it can affect anyone. Everyone needs to receive the best possible care and support to get back home to their families. We will continue to fight for justice for Lauren and for a better mental health system." Alexander Terry, an expert public law and human rights lawyer at Irwin Mitchell, the legal firm representing the family said: "Lauren's family believed there to have been significant failings in Lauren's care. Sadly, the inquest has validated those concerns and identified multi-agency failings. "By the time of her death, Lauren had been at Cheadle Royal for over seven months and she had been an out-of-area patient for over 500 days. She was desperate to be closer to home and this was known to everyone involved.A spokesperson for Dorset Health Care said: "Our deepest sympathies go to Lauren’s family and friends for their terrible loss. We can’t imagine their pain and grief. We have listened very carefully to all the evidence presented at this inquest and fully accept that the systems we had in place to bring people back to Dorset and closer to home were not what they should have been at the time of Lauren's death. A Priory spokesperson said: "The unexpected death of a young adult is devastating and we would like to express our sincere condolences to Lauren’s family. We fully support all initiatives for patients to be treated closer to home and our criteria for admitting patients is based on the nearest available bed. "Our hospital teams work hard to ensure patients can be discharged safely and at the earliest opportunity. Since Lauren’s sad death, we have put in place a stronger and more proactive process for patients whose discharge from hospital is delayed, to improve communications and escalate issues more quickly with the commissioners and NHS home services responsible for securing the patient’s next placement. "We continue to invest in making our wards safer. We will now reflect on the jury's findings and work openly with the NHS, commissioners, and regulators to ensure any further learnings are put into practice. We remain committed to providing safe and effective care to our patients."
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