A Coroner has concluded a six-day inquest hearing by returning an open verdict into the death of D’Anna Ward, aged 20, who was under the protection of a Community Treatment Order (CTO) at the time she took her own life. D’Anna hanged herself on 7th August and, despite the efforts of emergency services, she died in hospital four days later.
In a verdict that surprised the family, the Blackburn and District Coroner, John Singleton, failed to level any criticism at a number of mental health services for their failures in respect of a young woman who died in their care.
D’Anna Ward was brought up in Bingley, West Yorkshire. She started to develop mental health problems in her late teens. Having started to self-harm and put herself at risk, her father, Andrew Ward, took her to Lynfield Mount psychiatric hospital, Bradford (managed by the Bradford District Care Foundation Trust), and she was subsequently detained under the Mental Health Act.
She was identified as suffering from an Emotionally Unstable Personality Disorder and was referred to the Retreat Hospital, York, for specialist treatment. Unfortunately, D’Anna did not respond to the treatment and returned to Bradford. A further effort was made to find a specialist service for her, in the north of England so that she could maintain links with family, but the only appropriate service could not accept her: due to not having any available bed for the next 2-3 months and due to her low weight.
Despite her having self-harmed (including by ligature) during the summer of 2014, in hospital, a decision was made to discharge D’Anna to a supported living placement in the community at Prospects in Accrington, Lancashire. She was to be required to reside at that placement as a result of a Community Treatment Order. The plan was for The Bradford Trust to hand over D’Anna’s care after three months, but the handover was significantly delayed and did not in fact take place until 29th April 2015, a total of six months.
The family were represented at the inquest by Jim Gladman, Solicitor, and Michael Kennedy, Barrister, both of Switalskis Solicitors.
Jim Gladman said: “It has been very difficult indeed for D’Anna’s family to hear, over the past six days, just how many opportunities to help D’Anna were missed. They were very disappointed and upset at some aspects of the care provided by Prospects, at the time, but did not feel listened to. They are equally very disappointed that the Coroner felt that it could not have been reasonably anticipated that D’Anna would take her own life given her history of previously failed suicide attempts.
The family can only hope that the services concerned will reflect and learn from what happened, so that no other family goes through the ordeal they have. They ask that there is more investment in services for young women with complex personality disorders, as the lack of a comprehensive range of such services, in Yorkshire, and the pressure on beds in the local acute service, were in their view, the background to the decision to discharge D’Anna to an inappropriate service.”