- Jessie Eastland Seares died at Mill View Hospital in 2022
- Jury heard evidence of a lack of consistent and appropriate care for the 19 year old
- Coroner to write to Health Secretary over lack of community provision for people with Autism
A Jury has concluded that ‘systemic failures in health and social care’ lead to the tragic death of an Autistic teenager at a psychiatric hospital in East Sussex.
19-year-old Jessie Eastland Seares from Brighton died whilst she was an inpatient on Caburn Ward at Mill View Hospital in Hove in May, 2022.
Described by her family as kind, generous, funny, inspiring and unforgettable, Jessie had a history of complex neurodevelopmental, physical and mental health issues. She self-harmed, she was Autistic and she had been diagnosed with Dyspraxia, Ehlers Danlos Syndrome, ADHD (Attention Deficit Hyperactivity Disorder), Sensory Processing Disorder, depression and anxiety, and disordered eating.
Shortly before her death, Jessie had been living in temporary, emergency accommodation, supported by an unregulated agency, before being admitted to Royal Sussex County Hospital for physical issues, where she was later detained under Section 3 of the Mental Health Act.
She was admitted to Caburn ward – a unit for people with acute mental health problems which forms part of the Sussex Partnership Foundation Trust – on 4th March 2022.
At the time of her death, Jessie was on checks which should have taken place on an hourly basis. However, in the early hours of the 17th of May 2022, staff found Jessie ligatured and unresponsive. A doctor commenced CPR and an ambulance was called, but she sadly passed away.
During the two-week inquest, which took place in Brighton, a Jury heard evidence of a lack of consistency in the care that Jessie received, and that the care provided was not suitable to meet her needs.
East Sussex Council said they had tried over 30 ‘providers’ to help provide support to Jessie, but they could not find a suitable placement, so could only patch together supported housing with temporary agency staff.
Delivering a narrative verdict the Jury said that those failures caused her dysregulations that led to "regular bouts of self-harm" and ultimately her death.
Throughout the hearing the Jury also heard that nationally, there is a lack of community provision for the care and treatment of Autistic people which often leads to many experiencing unnecessary and inappropriate admission to inpatient facilities and A&E attendances.
Following the conclusion handed down on Friday December 1st, Coroner Penelope Scofield said she will be making a prevention of future death (PFD) report to the Secretary of State for Health and Social Care, saying that the lack of facilities available ‘contributed to Jessie death’, and that changes need to be made.
Speaking following the inquest, the family’s lawyer, public law expert Chris Callender from Sinclairslaw, said that a lack of appropriate services for people with complex physical, neurodevelopmental and mental health needs means that people with similar needs to Jessie would be failed.
“What we have heard throughout this inquest is that the care provided to Jessie was simply not suitable for her needs. Jessie experienced 30 different placements from the age of 14 years of age, and was no doubt in utter despair about her future when she died,” Chris said.
“What is deeply concerning in Jessie’s case was that rather than learn lessons and improve services for her care in the community, the Council appears to have given up and placed in her wholly unsuitable accommodation with a care team ill equipped and unsupervised, to look after a highly vulnerable young person. Ineveitably this culminated in her mental health deteriorating and yet another detention in psychiatric care. The Council were able to effectively wash their hands of any responsibility.
“The consequences, for Jessie, were catastrophic.
“It is imperative that action is now taken to improve the care that is available to people with complex neurodevelopmental, mental and physical health needs. That means a properly funded system, with training and adequate remuneration for staff and suitable accommodation for these vulnerable people.”
Jessie’s parents, Andy Seares and Katherine Eastland, added: “We are absolutely devastated that after fighting so hard and for so long to get the right care for Jessie, that the issues and concerns we raised time and time again ultimately contributed to her death.
“Jessie was a courageous person who struggled with her physical health and was not understood by authorities.
“Because of her high level of intelligence, she was often deemed to be far more capable than she was, and that meant that services failed to take her needs seriously. While we know that she was in considerable pain and distress, the very people who were supposed to help and support her often suggested she was simply attention seeking.
“Multiple services saw us as parents to be ‘managed’ rather than working in partnership with us, and sadly we know this is a very common experience for parents and carers in similar situations. Even throughout this inquest we felt that the Local Authorities continued to disrespect us rather than learn from their own failings.”
Andy and Katherine went on to say that they would now campaign for change in Jessie’s memory. “We have lost our precious child, and nothing will ever bring Jessie back,” they added. “However, we will continue to work with other families and organisations, including SPFT, to demand effective care provision, especially for autistic girls and women, and to hold this failed system to account.”
Jessie’s family were also supported by INQUEST at the hearing. Commenting on the findings of the Jury Luana D’Arco from the charity said: "Jessie was a young Autistic woman with complex physical and mental health needs, in need of specialist care and support. Instead, her death is yet another stark reminder that the one-size-fits all approach to young people's health, mental health and autism is not working.
Her story and those of so many other young women, must be the wake up call that leads to proper change and investment in appropriate person-centred, individualistic mental health and autism support.
Time and time again we see the concerns of families being ignored and young womens’ calls for help dismissed as 'attention seeking'. This reflects the culture within mental health services that urgently needs to change to ensure that young women like Jessie are kept safe.”
The family’s lawyer, Chris Callender from Sinclairslaw, went on to say that confusion surrounding the care that Jessie received specifically on the night Jessie died also highlighted ‘serious issues’ about the policies and procedures in place on Caburn Ward.
This included evidence heard throughout the inquest from several staff who had been on duty at Mill View on the night of her death who were unable to verify whether the hourly checks had taken place.
He added: “The staff were not clear on what they should report, and in what format. Tragically, Jessie’s family are now left wondering whether the observations were carried out correctly, or even carried out at all.
“That is completely unacceptable, and it is essential that appropriate action is taken to prevent future tragedies.”
Speaking following the inquest Andy and Katherine drew attention to the 2022 LeDeR report, which seeks to investigate and learn from the avoidable deaths of people with a learning disability and autistic people in England, which was published during Jessie’s inquest.
One finding which the family felt was very relevant to their own circumstances read ‘We also found a clear association between access to appropriate care and reductions in premature death, suggesting that, when the right level of care is provided, the level of risk goes down . . . ‘
Commenting on the report and their own experiences, Andy and Katherine added: “Mental health has been a 3rd class services for decades. Leaders know exactly what is needed but things are getting, worse not better. The Transforming Care programme has failed.”
For further information about the inquest, or to request interviews with Jessie’s family, INQUEST, or Chris Callender from Sinclairs Law please contact either Ashlea McConnell, PR Consultant acting for Sinclairs Law – firstname.lastname@example.org, 07852282802. Or Leila Haagman – INQUEST press team - email@example.com.
Deaths in the care of Sussex mental health services:
· Rachel Garrett, 22, died after falling from a height in Brighton on 29 July 2020. An inquest found that opportunities to save her life had been missed. Rachel had mental and physical health needs and had spent time in the care of Mill View Hospital. Media release.
· The Telegraph reported in January 2022 that more than 360 patients took their own lives after being treated by Sussex Partnership Foundation NHS Trust in the past five years. While there were also 15 coroner’s reports to prevent future deaths.
· Bethany Tenquist, 26, died after ligaturing in her room at Mill View Hospital on 16 January 2019. An inquest found a sequence of serious failures relating to staffing, leadership and safeguarding processes on ward probably had a direct causal connection to her death. Media release.
· Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care. Media release.
· In 2016, local media reported that five women had died at Mill View Hospital, including Janet Müller (above), Danuta Corbett, Jessica Philpott, Jackie Stansby, and Philippa Mortiz-Parsons.
· Sabrina ‘Sabby’ Walsh, 32, died on the Woodlands Ward in Sussex 2016. The inquest found gross failures and neglect contributed to her death. Media release.
· Bethan Smith, 31, died whilst under the care of Sussex Partnership Trust in 2011. Her mother wrote this about their experiences.