"Trust in the care of our mental health services", States say

Friday 27 September 2019

People are being urged to put their trust in the island's mental health service, after a Royal Court trial heard from professional and expert witnesses who said there are issues with the system.

Two former mental health nurses were on trial, but have now been acquitted of one charge each of Manslaughter by Gross Negligence.

While Naomi Prestidge and Rory McDermott did admit they were negligent at work - and didn't carry out any observation checks on their patient, Lauren Ellis, for one hour and 42 minutes - they pleaded not guilty to being criminally negligent, and therefore causing her death.

The Jurats cleared them by 7-2, after hearing from Judge Russell Finch who told the Court that convicting someone of that charge needs to meet an extremely high standard of proof.

Ms Ellis took her own life while on the Crevichon Ward at the Oberlands early in the morning of the 12 October 2017. She had agreed to be admitted to the ward the day before, because her self harming had got out of hand. 

But after a series of miscommunications between staff, Ms Ellis used a bandage she was given in the Emergency Department to ligature herself. 

Pictured: The trial lasted 17 days, and concluded in a not guilty verdict being delivered by a 7-2 margin. 

In the ensuing investigation, it was revealed that Ms Prestidge and Mr McDermott had been sat in the nurses station on their phones for nearly two hours, when they were both meant to be doing observation checks on Ms Ellis every  15 minutes. They even went as far as falsifying the records to pretend they had done those checks. 

In the eyes of the law, however, proving that those actions amounted to criminally and grossly negligent actions, and not just serious errors of judgement, was a difficult task. In the end, the islands' Royal Court cleared both Mr McDermott and Ms Prestidge, although they have both already faced professional disciplinary action. 

In his summing up, Judge Russell Finch clarified this: "Those who follow this case or read about it must understand that a conviction of manslaughter cannot rest just on negligence, but needs much, much more." 

The prosecution had to prove that the two nurses knew Ms Ellis taking her own life was a real and immediate possibility while they were failing to care for her. 

Pictured: The pair were cleared, but neither mental health worker now work for HSC. 

To argue this point during the trail, defending advocates Mark Dunster and Clare Tee pointing to miscommunications throughout the ward's staff, which meant their two clients were not fully aware at the time of how serious a risk Ms Ellis was to herself.

They thought she was asleep, they had not been told she was a ligature risk, and they did not know she had a bandage on her. They also pointed to actions taken by their superiors which indicated Ms Ellis was not going to try and take her life, like the fact she was not on one-to-one checks.

The defence's closing arguments can be read here. 

Expert witnesses who gave evidence during the trial put HSC and the island's mental health service under the microscope. It was revealed that a Root Cause analysis report of Ms Ellis death found more than 20 factors outlining why she died - the nurses' negligence in not doing their checks was just one. Those experts said it was also common for nurses on the ward to not carry out checks they were assigned.

In a statement following the result of the trial, however, Professor Juliet Beal, the Bailiwick's Chief Nurse, said the island's mental health service was still something that can be relied on. 

"This has been a deeply shocking and upsetting case.  First I want to say my thoughts, and those of my colleagues across Health and Social Care are with the family of Ms Ellis.  I cannot imagine what the past two years has been like for them." she said.

"While many things have been said during this hearing, it is not the Island’s mental health service that has been on trial, and the service has not had a voice.  I want to assure our community that they do have a good service they can be confident in.  Our healthcare professionals care deeply for their patients, and take their duties incredibly seriously.

"Following Lauren’s death and well before this hearing, Health & Social Care carried out internal and external investigations to identify any areas where it could improve services and improvements have been made.  But those investigations found a good standard of care was being provided.  It was and still is a good service, and islanders who need our help should still trust in the care they’ll receive."

HSC are expected to release the conclusion of the Root Cause Analysis report which looked into Ms Ellis' death in the near future. 

Pictured top: The Oberlands Centre which houses the Crevichon Ward.