NHS trust failings may have contributed to Bristol student’s death, inquest finds

A string of failings may have contributed to the death of a “deeply vulnerable” law student who killed herself while being treated in a psychiatric hospital in Bristol, an inquest jury has said.

Zoë Wilson, 22, had informed staff she was hearing voices in her head telling her to kill herself and 30 minutes before she died was seen by a nurse through an observation hatch looking frightened and behaving oddly but nobody went into her room to check her.

Speaking after the jury’s conclusions, Wilson’s family said that Avon and Wiltshire mental health partnership NHS trust (AWP) should face criminal charges over the case. AWP said it accepted it had fallen short in its care of Wilson.

The student was described by as a brilliant young woman, deeply loved by her family. In 2018 when she was in the final year of a law degree at Exeter University her mental health deteriorated, and she developed delusional behaviour with episodes of psychosis.

She returned to the family home in Bristol and in June 2018 she was admitted to hospital but discharged three months later.

Her condition deteriorated again and in April 2019 she was admitted to an acute facility at the psychiatric hospital Callington Road in Bristol, remaining there until 6 June 2019 when she was transferred to the Larch ward, which caters for lower-risk patients.

On 17 June 2019 she told staff she was hearing voices telling her to kill herself and handed over an item that she could have used to harm herself with. She was not moved to an acute ward and other items that she could have used were not removed.

At 1am on 19 June she was observed standing beside her bathroom door looking frightened but staff did not go to her. Thirty minutes later she was checked again and had harmed herself. Emergency services were called but she was pronounced dead.

Giving evidence to Avon coroner’s court, the nurse who saw Wilson at 1am said he had only worked in the unit a handful of times and had not met Wilson before that night.

The jury concluded that steps taken to keep her safe that night had been inadequate and also criticised communication and information sharing.

In a statement, her family, said: “Zoë was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward even when she told staff that voices in her head were telling her to kill herself.”

They called for AWP to face a criminal prosecution by the Care Quality Commission (CQC). “We will continue to fight for justice in her name,” they said. “She will never be forgotten.”

Tony Murphy of Bhatt Murphy solicitors, who represent the family, said: “The family now await the CQC’s investigation into the trust. Time is of the essence as the three-year anniversary of Zoë’s death approaches in June.“

Selen Cavcav, senior caseworker at the charity Inquest, said: “Zoe’s escalating mental health crisis should have rung alarm bells for the clinicians and other staff who were in charge of care.”

Dr Sarah Constantine, medical director at Avon and Wiltshire mental health partnership NHS trust said: “I would like to express my sincere condolences to the Wilson family. We accept the jury’s findings and recognise that in this instance we did not do everything that we could for Zoë.”

+ In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.