Investigation sought into health trust after 369 patients take their own lives following treatment

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Bethany Tenquist from Brighton, who took her own life while in the care of a mental health trust - Russell Sach
Bethany Tenquist from Brighton, who took her own life while in the care of a mental health trust - Russell Sach

More than 360 patients took their own lives after being treated by a mental health trust that was warned 15 times to improve care by coroners in the last five years, a Telegraph investigation has found.

Last night, bereaved families, MPs and charities called for an urgent investigation by ministers and health regulators into “repeated failings” and missed chances to prevent suicides.

Between 2016 and last year 369 patients at Sussex Partnership NHS Trust took their own lives, according to figures obtained by the Telegraph.

During the same period the trust was warned by coroners over a range of failures including incorrect discharges, medication errors, and a lack of supervision of mental health patients.

The trust provides mental health care to those in the county, including Chichester, the seat of Gillian Keegan, the current minister for mental health. She did not respond to a request for comment about her constituency.

Officials were told through letters from Sussex coroners, called prevention of future death reports, that action should be taken to prevent future deaths.

The family of one woman who hanged herself aged 26 on one of the trust’s wards, Bethany Tenquist, said that they felt that lessons had not been learned from her death.

Bethany Tenquist, who suffered with emotional personality disorder - Russell Sach
Bethany Tenquist, who suffered with emotional personality disorder - Russell Sach

Calling for Government intervention, Jeremy Hunt, the former health secretary and chair of the health and social care select committee, said: "These repeated incidents are deeply concerning and seem to warrant further investigation.

“Bereaved families deserve to know whether vital opportunities to learn lessons and prevent tragedies have been missed, and whether there are deeper, more systemic issues at this trust.

“I hope regulators and Ministers will look at this as a matter of urgency."

Dr Rosena Allin-Khan MP, Labour’s shadow cabinet minister for mental health, said: "The sheer number of people who have taken their own lives at the trust is deeply concerning.

"I hope regulators and Ministers will look into this matter and conduct an independent inquiry as a matter of urgency.

"Any inquiry must have the families of those who died at its heart. They’ve been waiting years for answers and have lost faith in the system."

In January last year, the then-health minister, Nadine Dorries, announced an inquiry into Essex NHS trusts following the deaths of 11 mental health in-patients between 2004 and 2015 in response to the recommendations of a Parliamentary and Health Service Ombudsman (PHSO) report.

Coroners seeking to improve the quality of care

Over the past five years coroners at inquests into patient deaths at Sussex have told the trust on 15 separate occasions to improve the quality of its care, as seven patients took their own lives on the Trust’s wards.

In 2016 the trust was warned after Joanne French,38, was discharged from hospital following communication errors by the trust between staff and the family.

She had been in hospital for just over a week after a serious attempt on her life. After being discharged she was found dead by a member of the public in Southwick, near Brighton.

In 2018 coroners said that another patient, Paul Hanton, 52, had absconded from care following a walk in the grounds in Crawley, after which he was found dead on train tracks in London. The coroner noted that nurses were not sure who was meant to be the one in charge of his care.

The next year the trust was told about another patient, John Richardson, 60, who also absconded from care after walking round the grounds of Meadowfield Hospital in Worthing.

Coroners noted that poor communication with the family, no risk assessments and no further care plans were key failings in their care. They were later found dead in woodland in the South Downs.

Also in 2019 the trust was warned over the death of Bethany Tenquist, 26, who was found hanged in her hospital room in Hove. The coroner said that an inadequate care plan, and a lack of training and staffing were serious concerns.

Bethany Tenquist pictured on holiday in France in 2012 - Russell Sach
Bethany Tenquist pictured on holiday in France in 2012 - Russell Sach

During the course of the inquest, the coroner felt he had to write to the trust for a second time, to warn them that vulnerable patients were continuing to self harm and dangerous objects were not being removed from their rooms.

In 2020, the trust was warned over the death of Cristopher Swain, 38, who was also found hanged in his room in Langley Green Hospital in Crawley. The coroner noted that “no formal review, care plan or adequate risk assessment was carried out in respect of his mental health.”

When he was eventually found by staff, he was believed to have been dead for some time.

Deborah Coles, Director of INQUEST, said: “Behind these deeply concerning figures are the lives of so many people who have died whilst under the care of the state, when they should have been safe and receiving help.

“After each death we hear platitudes about ‘learning lessons’ and yet preventable deaths continue and we see a clear and enduring pattern of failure of Sussex Partnership NHS Trust to deliver the systemic changes needed.

“While it is clear that issues in Sussex are particularly concerning, we know from our work that these are national issues.”

No Government plan to investigate

The Department of Health and Social Care spokesperson said that they had no plans to conduct an inquiry into Sussex, but that “every suicide is a tragedy and our sympathies go to the family and friends of those who have sadly died.”

They added that the inquiry into Essex will draw national conclusions.

A Sussex Partnership Trust spokesperson, said: “High quality care is our absolute priority. This is about keeping patients safe, providing effective treatment and working with people to make sure they have a positive experience of our services.

“A vital part of our work involves learning from serious incidents, listening to feedback and making the changes needed to improve patient care and treatment. We always try to do this in a way which promotes a culture of openness, honest reflection and action.

“Working closely with our health and care partners, we are committed to doing everything possible to avoid people feeling that taking their own life is their only option.”

Case Study: "She used to say 'I just don’t think they’re bothered about me'"

Beth Tenquist died in 2019, taking her own life in Mill View Hospital in Hove.

Last Sunday marked the three-year anniversary of her death.

The coroner found that there was a sequence of serious failures by Sussex Partnership NHS trust to keep her safe.

Her family, including her mother Bernadette, told the Telegraph that she would like to see an inquiry into the Trust, and would do anything to help those still on the wards.

They told the Telegraph that Beth had an eating disorder for around five years before her admittance to hospital, that came in part from being bullied at school.

Her family told the Telegraph she had “very little outpatient support”.

“It came out in the inquest that although she was requesting follow-up appointments, they were never sent to her.

“She used to say that “I feel unimportant” or “I just don’t think they’re bothered about me”.

“She coped for about six years on her own with an eating disorder, and then all of this issue blew up within the last two years before she died.

“The primary person who was supposed to look after her while in hospital, she said in the inquest that she had never seen anyone as ill as Beth. We were never told that at any point.

“It’s affected other people - another relative had a suicide attempt afterwards, because of it all.”

The family said that it was only after a meeting with the head of the Sussex Partnership, that they were given any help - over two years after Beth’s death.

“We just think it’s going to keep on happening.

“I’m sure people don’t essentially mean to be like this, you don’t go into the profession and be like this.

“My family had no experience of mental health problems before. It takes you a long time to learn what it is.”

The night that Beth died, the family told the Telegraph that staff did not react quick enough, and that there was a young doctor in charge of the whole hospital.

“The lady who found Beth, hanged on the door, a care assistant, the inquest was told that she still didn’t know what the name of a defibrillator was.

“The night Beth died, she was being bullied by another patient, who had psychosis and believed Beth was the person attacking her.

“She was so upset because the core of her problem was being bullied at school, and was now being bullied in this hospital by this other girl.

“We don’t know why they didn’t move either my daughter or the other girl to a different ward.

“If you’re incarcerated in a room for 24 hours, for your own safety, we thought she would be safer there than running around the streets or anything, but you are going to deteriorate, unless you’re given some sort of therapy or help.

“We don’t understand how you’re supposed to get better.”

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