AT Staines Magistrates’ Court on Monday a Surrey mental health service was ordered to pay £613,645.01 after Amy, 33 and a new mother, died in its care.

A prosecution was brought against it by the Care Quality Commission.

Priory Healthcare Limited pleaded guilty to failing to provide safe care and treatment to Amy at The Priory Hospital Woking. It was also ordered to pay a £2,000 victim surcharge and £11,645.01 in costs.

Amy admitted herself to the hospital as a voluntary patient on 15 March 2022 following a significant deterioration in her mental health, including suicidal thoughts. On admission, she was assessed as being at high risk and required appropriate care and protection.

On the evening of 21 March 2022, Amy was found unresponsive. Despite efforts to assist her, she was pronounced dead shortly afterwards. An inquest later ruled that she had taken her own life by suspension.

In concluding the inquest on 23 February 2023, the coroner recorded a narrative conclusion of suicide, finding that neglect had contributed to Amy's death. The inquest concluded that failures to adequately manage a known and previously identified environmental ligature risk contributed to Amy’s death by neglect.

The central failure was Priory’s long-standing inability to adequately manage a known ligature risk in a ground-floor disabled toilet accessible to people. Despite ligature point audits having flagged the risk in March 2020 and again in May 2021 no effective action was taken to restrict access to the room.

Rosalind Sanderson, CQC’s deputy director of enforcement, said:  “Our sympathies are with the family and friends of Amy following the sad death, which was potentially preventable. 

“People receiving care and treatment have the right to expect that any risks to their safety will be effectively managed. This isn’t what happened when Amy was in the care of The Priory Hospital Woking.”

A Priory spokesperson said: “We deeply regret the failings that occurred during Amy's admission in 2022 and our thoughts and sympathies remain with her family.

“Events involving the tying of a ligature by high-risk patients are a known risk factor across all NHS and independent mental health hospitals and, like all providers, we continue to work hard to manage and mitigate these risks while also ensuring patients receive the least restrictive care possible.

“Immediately following the incident, action was taken to prevent patients accessing the toilet, including changes to the door locking mechanism. The investigation also prompted improvements to missing person search procedures and ligature risk management.

“The organisation also undertook a wider review of practice, identifying further opportunities to strengthen patient safety.

“These actions were recognised by CQC (in December 2022) when it improved the hospital's rating from “Requires Improvement” to “Good”, a rating it continues to hold today.

“We want to reiterate our deepest condolences to Amy's family and friends. We hope that the immediate and lasting improvements made in response to this tragedy reflect the profound impact her death has had.”