17 Dec Jury concludes that ward failures led to death of Jessica Powell

The inquest touching upon the death of Jessica Powell has concluded, with the jury finding that the acute mental health ward in which she was detained failed to adequately supervise and secure a room which was fitted with windows that Jessica might reasonably believe she could escape through, and that she died trying to climb through one of those windows.

The hearing took place at Wells Town Hall from 9 to 16 December 2024 before Assistant Coroner Vanessa McKinlay of Somerset Coroner’s Court.

Jess died on 22 August 2020 following the incident on 19 August 2020 at Rowan Ward, Summerlands Hospital in Yeovil, Somerset. She was 20 years old.

Jess had a diagnosis of Emotionally Unstable Personality Disorder (“EUPD”), but the jury heard that she was more than her illness; she was determined, intelligent, funny and loving. Her parents recalled in their statements that Jess had made significant academic achievements even while she was admitted – she had got her Maths and English GCSE’s and started studying for a degree.

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. The jury heard that she 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, Christoper House, which her parents raised serious concerns about. Her parents would later learn that she was raped in this accommodation. The court heard that Jess’s attempts of living in the community had not worked.

From October 2019 until she died, Jess was detained on Rowan Ward under section 3 of the Mental Health Act. The jury heard that, as a result of her EUPD, Jessica could be impulsive, struggled to regulate her emotions, and used self-harm to manage her distress. The jury heard that her self-harm was extensive and was 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 Jess’s mood could be very changeable.

Jess’s parents’ evidence was that they regularly spoke with staff to make them aware of their concerns about Jess. 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, and 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 section 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, including obtaining illicit drugs for the purpose of overdose. 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 Jess.

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 that she had not attended for 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 Court 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 concluded 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. Jessica deliberately tried to climb through the window and it was not her intention to end her life by doing so.

The jury also recorded the following description of how Jessica came by her death:

Jessica had been known to mental health services since the age of 12. Aged 16 she was first detained through section 3 of the Mental Health Act with a diagnosis of EUPD. In October 2019, she was detained under section 3 on Rowan Ward due to risk of harm to herself and others.

From January to March 2020, Jessica was admitted to PICU (Psychiatric Intensive Care Unit) because of escalating self harm behaviour, which also caused harm to staff. There were over 60 incidents of self harm from January to August 2020, including cutting, ingesting objects, inserting objects under skin, ligaturing, disordered eating and obtaining and taking illicit drugs. In May 2020, Jessica succeeded in absconding from Rowan Ward through a dining room window, despite this being fitted with restrictors that should have limited the aperture to 10cm. Jessica had no recorded incidents of self harm in the 10 days prior to the incident.

On 19 August 2020, Jessica was last seen at around 10.20pm when she collected her mobile phone from the office. Staff noted that she did not collect her 10pm medication and commenced a search. She was discovered (by a single member of staff) trapped in the window of the Therapy Room, at some time between 10.30 and 10.40pm.

Absconsion was a well-documented feature of Jessica’s EUPD. The door to the Therapy Room had been left unlocked, despite Jessica’s successful attempt to abscond through a similar window in May 2020. The type of window in the Therapy Room had been selected based on the principle that there would be no unsupervised access to this room. Jessica was able to lock the room from the inside and turn off the light, detracting attention from her presence in the room.

When discovered, the member of staff activated his PIT alarm. Failure to update the alarm system meant that alerted staff went to the wrong room to provide assistance and there was a delay in help arriving. A 999 call was made at 10.43pm. Staff were unable to release Jessica from the window. Access to Jessica from the outside was impeded because the exterior door could not be opened, as it was on a separate key system (not regularly carried by staff). The fire door adjoining the Therapy Room could not be used to easily access her either and staff instead had to run around the outside of the building and manually force the window to release Jessica.

CPR was commenced but resuscitation was not successful. This suggests that Jessica had been trapped more than momentarily. Paramedics arrived at 22.50 and began advanced resuscitation, successfully restarting Jessica’s heart prior to transport to Yeovil District Hospital at 23.57.

Owing to a sustained period of cardiac arrest, resulting in hypoxic ischaemic brain injury, Jessica was not able to recover and was pronounced dead at 13.26 on 22 August 2020 at Yeovil District Hospital.

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.

There is also so much that happened earlier in her life that the jury couldn’t look at because it didn’t fall within the scope of the inquest. She was failed from day one. We often feel that the worst thing we ever did was put her into the first CAMHS unit, because that was the point at which we lost control. She was thrown to the wolves at Christopher House as she was vulnerable and naïve because of all the time she had spent in mental health units as a teenager.

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 4 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.

Alongside her illness, Jess was interesting, clever, and loving. She was a very special person. She did well in her studies and got really impressive marks in her university courses, despite being in hospitals for most of her life from about 12 years old.

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 4 years; that Jess posed risks to herself that weren’t managed carefully enough, and that this played a role in her death.  That they have had to wait so long for this conclusion is an alarming illustration of the intolerable pressures under which the coroners’ courts are operating, and of the real impact this is having on grieving families.  It is also a concern that inquests are not able to identify problems which can then be rectified in a timely manner and before other lives are put at risk.

ENDS

Notes for editors:

1. Jessica Powell’s family is represented by Ruth Mellor and Emma Gregg of Deighton Pierce Glynn solicitors, and by Ben McCormack of Garden Court North Chambers. They are also supported by the charity INQUEST.
2. Request for photographs and further information should be directed to bristoladmin@dpglaw.co.uk.

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